Management of Post-Surgical Shoulder Pain with Neuropathic Features
Given the electric shock sensation with overhead movements in a patient with prior shoulder repair and normal X-rays, this presentation is most consistent with nerve irritation or neuropathic pain, and you should obtain an MRI without IV contrast to evaluate for nerve compression, soft tissue pathology, and rotator cuff integrity. 1, 2
Initial Diagnostic Approach
The X-ray has already excluded acute fracture and hardware loosening, so advanced imaging is now indicated. 1, 2
MRI without IV contrast is the primary next study for evaluating the postoperative shoulder when radiographs are noncontributory, as it can assess nerve structures, rotator cuff integrity, labral pathology, and soft tissue inflammation that may be causing nerve irritation. 1, 2
The electric shock sensation strongly suggests nerve involvement—most commonly suprascapular nerve irritation or axillary nerve compression—which MRI can help identify through visualization of nerve compression sites, muscle denervation patterns (edema in supraspinatus/infraspinatus for suprascapular nerve), and associated soft tissue masses or scar tissue. 2
In postoperative shoulders, MRI plays an important role in evaluating hardware-related complications and can demonstrate soft tissue abnormalities even when hardware appears intact on radiographs. 1
Alternative Imaging Considerations
Ultrasound may be preferred over MRI if there is significant metallic artifact from the prior repair hardware that would limit MRI examination quality, as ultrasound can effectively evaluate rotator cuff integrity and surrounding soft tissues in the postoperative setting. 1
However, ultrasound has limitations in evaluating deep structures and nerve pathology, making MRI the superior choice when nerve involvement is suspected. 1
Management Algorithm Based on MRI Findings
Conservative management should be initiated while awaiting or immediately after MRI:
Start neuromodulating medications such as gabapentin (starting 300 mg daily, titrating to 900-1800 mg divided three times daily) or pregabalin (75-150 mg twice daily) for the neuropathic pain component indicated by the electric shock sensation. 2
NSAIDs (ibuprofen 400-800 mg three to four times daily) for any inflammatory component, combined with structured physical therapy focusing on scapular stabilization and avoiding provocative overhead positions initially. 2
Patient education on activity modification, avoiding repetitive overhead movements that trigger symptoms during the acute phase. 2
If conservative management fails after 6-12 weeks:
Consider suprascapular nerve blocks as an interventional option, particularly if MRI confirms nerve compression or if symptoms localize to the suprascapular nerve distribution. 2
Surgical referral is indicated for progressive neurological deficits, failed adequate conservative management (typically 3-6 months), or if MRI reveals structural pathology requiring surgical correction such as hardware impingement on neural structures. 2
Critical Pitfalls to Avoid
Do not dismiss neuropathic symptoms as "normal postoperative pain"—electric shock sensations warrant specific evaluation for nerve pathology and targeted treatment with neuromodulating agents rather than just NSAIDs. 2
Do not order MR arthrography in this acute postoperative setting—it is not indicated and standard MRI without contrast is sufficient and appropriate for evaluating the postoperative shoulder. 1
Be aware that in postoperative shoulders, persistent signal abnormalities within soft tissues may hinder assessment, so correlation with clinical examination findings is essential. 3