Shoulder Pain Treatment and Medication
First-Line Treatment Approach
Begin with activity modification, gentle stretching focusing on external rotation and abduction, and ibuprofen 400-800 mg every 6-8 hours, which is superior to acetaminophen for rotator cuff-related pain. 1, 2, 3
Initial Conservative Management
Start gentle passive and active-assisted range of motion exercises within the patient's visual field, specifically targeting external rotation and abduction movements to address impingement mechanisms and prevent frozen shoulder 4, 1, 2
Apply ice before each exercise session for symptomatic relief and pain reduction 4, 1, 2
Prescribe ibuprofen 400-800 mg every 6-8 hours (available as 400 mg, 600 mg, or 800 mg tablets), taken preferably before bedtime to improve sleep quality 1, 2, 5, 3
- Evidence shows ibuprofen provides superior improvement in pain severity and functional activity compared to acetaminophen for rotator cuff-related pain 3
Implement soft tissue massage to reduce pain and improve tissue elasticity 4, 1
Ensure proper sleep positioning - never allow sleeping on the affected shoulder 1, 2
Critical Pitfall to Avoid
Avoid overhead pulley exercises entirely - these encourage uncontrolled abduction and have the highest incidence of developing hemiplegic shoulder pain 4, 1
Progression Phase (Weeks 4-8)
Advance to intensive strengthening exercises targeting rotator cuff and scapular stabilizers once acute pain improves 1, 2
Emphasize posterior shoulder musculature strengthening and address any scapular dyskinesis 1, 2
Implement graduated return to overhead activities with proper mechanics 1, 2
Second-Line Interventions
Corticosteroid Injections
Consider subacromial or intra-articular corticosteroid injection (triamcinolone) when pain is clearly related to rotator cuff or bursa inflammation and conservative measures have failed. 4, 1, 2, 6
Intra-articular triamcinolone injections have significant effects on pain reduction 4
The injection site (subacromial, acromioclavicular joint, or intra-articular) depends on the specific diagnosis 6
Glenohumeral joint injections should be performed under fluoroscopic guidance 6
Alternative Injection Therapies
Suprascapular nerve blocks may be considered as adjunctive treatment, showing superiority to placebo in reducing shoulder pain for up to 12 weeks 4
Botulinum toxin injection can be useful to reduce severe hypertonicity in shoulder muscles, particularly when spasticity-related joint mobility restrictions contribute to pain 4
Diagnostic Adjuncts
- Consider ultrasound evaluation to assess for structural pathology if not improving after 3-4 weeks of conservative management 1, 2
Specialized Considerations
For Neuropathic Pain Component
Trial neuromodulating pain medications when clinical signs suggest neuropathic pain (sensory changes, allodynia, or hyperpathia in the shoulder region) 4
Electrical Stimulation
Neuromuscular electrical stimulation (NMES) may be considered for shoulder pain, though evidence shows it primarily improves pain-free lateral rotation rather than overall pain intensity 4
Functional electrical stimulation can be used as an adjunctive treatment 4
When to Refer
Refer to orthopedic specialist if symptoms persist or worsen after 6-12 weeks of directed conservative treatment. 6, 7
Surgical Options (After Failed Conservative Management)
Surgical tenotomy of pectoralis major, latissimus dorsi, teres major, or subscapularis may be considered for patients with severe restrictions in shoulder range of motion 4
Arthroscopic subacromial decompression or rotator cuff repair may be indicated based on specific pathology 8
Key Clinical Assessment Points
Look for painful arc between 60-120° of abduction/flexion - this is pathognomonic for subacromial pathology (rotator cuff or bursal inflammation) 1, 2
Evaluate muscle tone, spasticity, soft tissue changes, joint alignment, and test for regional sensory changes to identify specific impairments 4
Normal rotator cuff strength rules out full-thickness tear 1, 2
Evidence Quality Note
The strongest guideline evidence comes from the American Heart Association/American Stroke Association (2016) for hemiplegic shoulder pain 4, though many principles apply to general shoulder pain. The 2005 stroke rehabilitation guideline 4 and recent synthesis of clinical guidelines 1, 2 provide convergent recommendations. Research evidence consistently supports ibuprofen superiority over acetaminophen specifically for rotator cuff-related pain 3.