What is the best course of treatment for a patient with ongoing shoulder blade pain, numbness, and functional limitation of the shoulder following a minor motor vehicle accident (MVA) with whiplash and shoulder sprain, who is currently taking Celecoxib (celecoxib) for pain management?

Management of Post-MVA Shoulder Blade Pain with Neuropathic Symptoms

Direct Recommendation

Continue celecoxib and immediately initiate a structured therapeutic exercise program focusing on gentle passive range of motion progressing to active-assisted exercises, with specific emphasis on external rotation and abduction movements, while adding bedtime ibuprofen for superior nocturnal pain control. 1, 2

Treatment Algorithm

Immediate Interventions (Current - Week 3)

Pharmacologic Management:

• Continue celecoxib 200 mg twice daily, as it has demonstrated superior efficacy for nocturnal pain in shoulder conditions compared to other NSAIDs and is at least as effective as naproxen for acute shoulder pain 3, 4, 5
• Add ibuprofen before bedtime specifically for sleep quality improvement, as it is superior to acetaminophen for rotator cuff-related pain and addresses the nocturnal symptoms this patient experiences 1
• Regular paracetamol can continue as adjunctive analgesia 1

Physical Therapy Protocol:

• Start gentle passive and active-assisted range of motion exercises immediately, placing the arm in safe positions within the patient's visual field to prevent adhesive capsulitis development 1
• Apply ice before each exercise session for symptomatic relief and pain reduction 1
• Focus specifically on external rotation and abduction movements to address the impingement mechanism and functional limitation 1
• Never allow sleeping on the affected shoulder - proper positioning during sleep is crucial for recovery 1

Critical Pitfall to Avoid

Do not use overhead pulleys or allow static positioning/strapping of the upper extremity, as these dramatically increase shoulder pain and risk of complications, particularly given the whiplash mechanism and possible ulnar nerve involvement 1, 6

Progression Phase (Weeks 4-8)

If improving after 3-4 weeks:

• Advance to intensive strengthening exercises targeting rotator cuff and scapular stabilizers 1
• Emphasize posterior shoulder musculature strengthening and address any scapular dyskinesis 1
• Implement graduated return to overhead activities with proper mechanics 1

If NOT improving after 3-4 weeks:

• Consider subacromial corticosteroid injection when pain is clearly related to rotator cuff or bursa inflammation 1
• Obtain MRI imaging to assess for structural pathology beyond the normal ultrasound findings, particularly given the persistent neuropathic symptoms 1
• Refer to orthopedic specialist for evaluation of possible surgical intervention, though rotator cuff repair is only weakly recommended for chronic symptomatic tears 7

Addressing the Neuropathic Component

The pinching sensation with numbness/ache radiating down the arm suggests cervical radiculopathy or peripheral nerve compression:

• The therapeutic exercise program will help restore proper shoulder alignment and reduce muscle spasm that may be compressing the ulnar nerve 1
• If neuropathic symptoms persist despite improved shoulder mechanics, consider restarting amitriptyline (which the patient reported helped with pain) or referral to neurology for nerve conduction studies 6

Evidence Strength Considerations

The recommendation for therapeutic exercise is supported by strong research evidence showing positive effects on pain and function across shoulder conditions 2. The specific exercise protocol comes from high-quality 2025 guideline recommendations 1. Celecoxib's efficacy is demonstrated in multiple randomized controlled trials specifically for shoulder tendinitis/bursitis 3, 4, 5, making it an appropriate ongoing choice for this patient.

The key distinction here is that this patient has completed initial physiotherapy without adequate resolution, suggesting the need for a more intensive, structured approach with specific attention to preventing adhesive capsulitis while addressing the neuropathic component 1, 8.

Return to Work Considerations

Ensure complete resolution of symptoms before returning to full overhead activities if the patient's work involves such movements 1. Since work currently doesn't aggravate symptoms, gradual return may be appropriate as function improves, but functional limitations must resolve first to prevent chronic disability 8.