What medications are recommended for shoulder pain?

Medication for Shoulder Pain

Start with oral NSAIDs (ibuprofen 400-800 mg every 6-8 hours) as first-line pharmacologic treatment for shoulder pain, as they provide superior pain relief and functional improvement compared to acetaminophen, particularly for rotator cuff-related conditions. 1, 2, 3

First-Line Pharmacologic Approach

Oral Analgesics

• Ibuprofen is the preferred oral medication for rotator cuff-related shoulder pain, demonstrating significant improvement in pain severity and functional activity (measured by SPADI and Quick-DASH scores) after 6 weeks of treatment at doses of 400-800 mg every 6-8 hours 3
• Acetaminophen can be used as an alternative first-line agent for patients with contraindications to NSAIDs, though it shows less improvement in pain and function compared to ibuprofen 1, 2, 3
• Topical NSAIDs should be considered for mild to moderate pain as they provide fewer systemic side effects while maintaining analgesic efficacy 1

Oral Corticosteroids

• A short course of oral corticosteroids may be considered when significant inflammation is present, though evidence supporting this approach is limited 1

Second-Line Injectable Therapies

Corticosteroid Injections

• Subacromial or intra-articular corticosteroid injections are appropriate when oral medications fail and inflammation of the rotator cuff, bursa, or joint is suspected 2, 4, 5
• The American Academy of Orthopaedic Surgeons notes insufficient evidence to definitively recommend for or against intra-articular corticosteroid injection specifically for glenohumeral osteoarthritis, though they are widely used in clinical practice 6
• Corticosteroid injections provide short-term pain reduction but long-term benefits have not been verified 2
• Ultrasound guidance should be considered to verify structural pathology and improve injection accuracy 4

Viscosupplementation

• Injectable sodium hyaluronate (Hylan G-F 20) is an option for glenohumeral osteoarthritis, administered as three weekly injections, with improvements in pain and function lasting up to 6 months 6

Nerve Blocks

• Suprascapular nerve blocks can reduce pain for up to 12 weeks and are particularly useful for hemiplegic shoulder pain or refractory cases 2
• Botulinum toxin injections into shoulder muscles are useful for reducing severe hypertonicity and associated pain in spasticity-related shoulder conditions 2

Muscle Relaxants (Limited Role)

• Cyclobenzaprine may be considered for acute musculoskeletal shoulder pain with associated muscle spasm, though it is not specifically indicated for shoulder pain 7
• The standard dose is 5-10 mg three times daily, with elderly patients starting at 5 mg and titrating slowly 7
• Common side effects include drowsiness and dry mouth, which may limit tolerability 7

Critical Clinical Algorithm

Step 1: Begin with oral ibuprofen 400-800 mg every 6-8 hours (or topical NSAIDs for mild pain) combined with physical therapy 1, 2, 3

Step 2: If inadequate response after 2-4 weeks, add subacromial corticosteroid injection while continuing NSAIDs and physical therapy 2, 4

Step 3: For persistent pain despite injections, consider viscosupplementation for osteoarthritis or suprascapular nerve block for refractory cases 6, 2

Step 4: Refer for surgical evaluation if conservative measures fail after 3-6 months 6

Important Caveats and Pitfalls

• Do not rely on acetaminophen alone for rotator cuff-related pain, as it demonstrates inferior outcomes compared to NSAIDs in functional improvement 3
• Avoid delaying treatment, as untreated shoulder pain can mask motor function improvement, inhibit rehabilitation, and contribute to depression, insomnia, and reduced quality of life 2
• Take ibuprofen before bedtime to improve sleep quality in patients with nighttime shoulder pain 4
• Corticosteroid injections should be used judiciously as they provide only short-term relief and repeated injections may have detrimental effects on tendon integrity 2
• Always combine pharmacologic treatment with physical therapy emphasizing gentle stretching (external rotation and abduction), mobilization, and progressive strengthening of rotator cuff and scapular stabilizers 1, 2, 4
• Avoid overhead pulley exercises as they encourage uncontrolled abduction and may worsen shoulder pathology 1, 2, 4