What are the treatment options for right shoulder pain?

Treatment of Right Shoulder Pain

Begin with standard radiography (AP views in internal and external rotation plus axillary or scapular Y view) to rule out fracture, dislocation, or malalignment, then initiate conservative management with NSAIDs and exercise therapy for 8-12 weeks before considering advanced imaging or interventions. 1, 2, 3

Initial Diagnostic Imaging

• Radiography is the mandatory first step for any acute shoulder pain presentation, as it rapidly identifies fractures, dislocations, and shoulder malalignment that require immediate management 1, 2
• The minimum radiographic series must include three views: anteroposterior in internal rotation, anteroposterior in external rotation, and either axillary lateral or scapular Y view 1, 2
• The axillary or scapular Y view is critical because acromioclavicular and glenohumeral dislocations are frequently misclassified on AP views alone 1

Conservative Treatment Protocol (First-Line)

For patients without fracture or dislocation on radiographs, initiate the following 8-12 week trial:

• NSAIDs at therapeutic doses: Ibuprofen 400 mg every 4-6 hours (maximum 3200 mg daily), taken with meals or milk to minimize gastrointestinal complaints 3, 4
• Structured exercise program focusing on external rotation and abduction movements, which demonstrates significant pain reduction at 8 weeks and functional improvement by 3 months 3
• Activity modification avoiding overhead movements and overhead pulley exercises, which encourage uncontrolled abduction and may worsen symptoms 2, 3

Common Pitfall to Avoid

Do not use overhead pulley exercises—they are specifically contraindicated as they promote uncontrolled abduction that can aggravate shoulder pathology 2

Advanced Imaging (If Conservative Treatment Fails at 8-12 Weeks)

The choice of advanced imaging depends on patient age and suspected pathology:

• For patients under 35 years: MR arthrography is preferred (rated 9/9 appropriateness) because instability and labral tears are the predominant pathology in this age group 1, 2
• For patients over 35 years: Standard MRI without contrast is sufficient (rated 7/9 appropriateness) as rotator cuff disease predominates in older patients 1, 2
• Ultrasound is an equivalent alternative (rated 9/9 appropriateness) for evaluating rotator cuff tears and can guide therapeutic injections if local expertise is available 1, 2, 3

When CT is Appropriate

• CT without contrast is indicated only when radiographs show complex or comminuted fractures requiring detailed characterization for surgical planning 1
• CT can change clinical management in up to 41% of proximal humeral fractures by better defining fracture morphology 1

Interventional Options (After Failed Conservative Management)

Consider these interventions only after 8-12 weeks of failed conservative therapy:

• Subacromial corticosteroid injection may be considered for patients with confirmed inflammation, though evidence for efficacy is not well established 1
• Suprascapular nerve block can be considered as adjunctive treatment for persistent pain 1
• Avoid corticosteroid injections in patients with osteopenia as they may further compromise bone density 3

Special Consideration: Suspected Septic Arthritis

If septic arthritis is suspected (fever, acute onset, systemic symptoms), ultrasound-guided or X-ray-guided arthrocentesis is the procedure of choice (rated 9/9 appropriateness) and takes priority over all other interventions 1, 2

Immediate Surgical Referral Criteria

Refer urgently to orthopedic surgery if any of the following are present:

• Unstable or significantly displaced fractures on radiographs 2
• Glenohumeral joint instability that cannot be reduced 2
• Neurological deficits suggesting nerve injury 2
• Suspected massive rotator cuff tear requiring expedited repair for optimal outcomes 2

Treatment Algorithm Summary

1. Week 0: Obtain three-view radiographs (AP internal/external rotation + axillary or Y view) 1, 2
2. Week 0-8: If no fracture/dislocation, start ibuprofen 400 mg every 4-6 hours + structured exercise program + activity modification 3, 4
3. Week 8-12: Reassess response; if significant improvement, continue conservative management 3
4. Week 12+: If inadequate response, obtain MRI (age >35) or MR arthrography (age <35) to evaluate for full-thickness rotator cuff tear or labral pathology 1, 2, 3
5. Consider interventions (corticosteroid injection, nerve block) only after imaging confirms specific pathology and conservative measures have failed 1, 3
6. Surgical consultation reserved for confirmed full-thickness tears not responding to 3-6 months of conservative management or for acute fractures/dislocations requiring operative fixation 2, 3

Key Evidence Consideration

The most recent ACR guidelines (2025) emphasize that radiography remains the cornerstone of initial evaluation, and the 2025 Praxis synthesis confirms that early intervention within the first 8-12 weeks positively influences treatment response, making prompt conservative management initiation critical 1, 2, 5