What is the initial management approach for a patient presenting with shoulder pain in a primary care setting?

Initial Management of Shoulder Pain in Primary Care

Begin with a structured clinical assessment focusing on red flag identification, followed by a trial of conservative management centered on physical therapy with gradual range-of-motion exercises and analgesics, reserving imaging and specialist referral for patients who fail to improve after 6-12 weeks or present with concerning features. 1, 2

Immediate Assessment Priorities

Screen for Red Flags Requiring Urgent Referral

• Acute trauma with suspected fracture or dislocation 1
• Signs of infection (fever, erythema, warmth) 1
• Neurological deficits suggesting cervical spine pathology or nerve injury 3
• Suspected malignancy (unexplained weight loss, night pain unrelieved by rest, history of cancer) 1
• Vascular compromise 3

Evaluate Psychosocial Factors

• Assess for depression, anxiety, catastrophizing, and fear-avoidance behaviors as these predict poor outcomes 1
• Identify work-related concerns and disability expectations 1
• Screen for sleep disturbance which commonly accompanies chronic shoulder pain 1

Conduct Targeted Physical Examination

• Evaluate shoulder strength, range of motion (particularly external rotation and abduction), and impingement signs 1, 4
• Assess for shoulder subluxation in patients with neurological conditions 1
• Perform neurological screening to rule out cervical radiculopathy 3
• Test for specific pathology: rotator cuff disease, adhesive capsulitis, acromioclavicular joint pathology, biceps tendinopathy 3, 5

Initial Conservative Management (First 6-12 Weeks)

Patient Education and Self-Management

• Provide clear information about the diagnosis, expected recovery timeline, and importance of staying active 1
• Educate on proper positioning and activity modification to avoid aggravating movements 1, 4
• Teach home exercises for maintaining range of motion 1

Physical Therapy as First-Line Treatment

• Prescribe structured physical therapy emphasizing gentle stretching and mobilization techniques focused specifically on external rotation and abduction to prevent frozen shoulder 1, 4
• Gradually increase active range of motion while restoring proper shoulder alignment and strengthening weak muscles in the shoulder girdle 1, 4
• Progress to intensive strengthening of rotator cuff and scapular stabilizers as pain allows 4
• Address scapular dyskinesis through specific exercises, as this is essential for successful outcomes 4
• Avoid overhead pulley exercises as they encourage uncontrolled abduction and may worsen pain 1, 4

Pharmacological Management

• Start with acetaminophen or ibuprofen for initial pain relief 1, 4
• Consider topical NSAIDs for mild to moderate pain with fewer systemic side effects 4
• Avoid routine opioid use for chronic shoulder pain 1

Adjunctive Modalities

• Apply ice or heat before exercises for symptomatic relief 1, 4
• Consider soft tissue massage to reduce pain and improve tissue elasticity 1, 4

Selective Use of Imaging

When to Order Imaging

• Do NOT routinely order imaging for uncomplicated shoulder pain 1
• Order plain radiographs (AP in internal/external rotation plus axillary or scapula-Y view) if:
  • Trauma with suspected fracture or dislocation 1
  • Failure to improve after 6 weeks of conservative treatment 2
  • Red flags present 1
• Reserve MRI or ultrasound for:
  • Persistent symptoms after 6-12 weeks of appropriate conservative care 2
  • Suspected full-thickness rotator cuff tear requiring surgical consideration 1
  • Diagnostic uncertainty affecting management decisions 1, 3

Corticosteroid Injections (Adjunctive Treatment)

Indications and Technique

• Consider subacromial corticosteroid injection for pain thought related to rotator cuff pathology or subacromial bursitis when conservative measures provide insufficient relief 1
• Use intra-articular glenohumeral injection for adhesive capsulitis 2
• Inject acromioclavicular joint for isolated AC joint pathology 2
• Combine with ongoing physical therapy rather than using as standalone treatment 2

Special Consideration for Spasticity-Related Pain

• Consider botulinum toxin injection into subscapularis and pectoralis muscles for shoulder pain related to spasticity (post-stroke patients) 1
• Suprascapular nerve blocks may be effective for reducing both nociceptive and neuropathic shoulder pain components 1

Monitoring and Follow-Up

Track Patient Progress

• Reassess at 3 weeks, then at 3,6, and 12 months using standardized outcome measures 1, 6
• Use the Shoulder Pain and Disability Index (SPADI) to quantify improvement 6
• Expect significant improvement by 3 weeks if treatment is effective; lack of improvement suggests need for reassessment 6

Keep Patients at Work

• Provide work modifications and graduated return-to-work plans rather than complete work cessation 1
• Address workplace ergonomics contributing to shoulder pain 1

Referral to Specialist

Indications for Orthopedic Referral

• Failure to improve after 6-12 weeks of directed conservative treatment 5, 2
• Worsening symptoms despite appropriate management 2
• Suspected full-thickness rotator cuff tear with persistent symptoms after 3 months of non-surgical care 1
• Acute injuries requiring surgical consideration (displaced fractures, acute dislocations) 1, 5
• Severe restriction in range of motion unresponsive to therapy 1

Common Pitfalls to Avoid

• Do not order MRI or advanced imaging as initial investigation unless red flags present 1
• Do not prescribe overhead pulley exercises as they worsen impingement 1, 4
• Do not continue ineffective treatment beyond 12 weeks; refer patients who show no improvement 7
• Do not use glucosamine or chondroitin for shoulder osteoarthritis (no disease-modifying effect) 1
• Do not perform arthroscopic lavage and debridement unless mechanical symptoms present 1
• Do not neglect psychosocial assessment, as these factors strongly predict outcomes 1

Expected Outcomes

• 32.9% of patients achieve excellent outcomes by 3 months, increasing to 45.3% by 12 months 6
• Approximately 15-17% of patients remain unchanged or worse at 12 months despite appropriate treatment 6
• Significant improvement typically occurs within 3 weeks if treatment is effective, with further gains at 12 months 6