What is the best approach for managing severe shoulder pain with a severity of 9/10?

Approach to Severe Shoulder Pain (9/10)

For severe shoulder pain rated 9/10, immediately obtain upright radiographs with at minimum three views (AP in internal and external rotation plus axillary or scapula-Y view) to rule out fracture, dislocation, or malalignment, then provide immediate analgesia with acetaminophen or ibuprofen while determining if the injury requires urgent surgical referral versus conservative management. 1, 2, 3

Immediate Clinical Assessment

Your first priority is determining whether this is traumatic or non-traumatic pain, as this fundamentally changes management:

• Obtain mechanism of injury: Traumatic shoulder pain (from acute or chronic trauma) suggests fracture, dislocation, or acute soft-tissue injury requiring different management than atraumatic causes 1, 3
• Assess for red flags requiring urgent referral: Significant trauma, joint instability, neurological symptoms, or inability to move the shoulder 3
• Evaluate for stroke-related pain: If the patient has stroke history, consider hemiplegic shoulder pain which requires specialized assessment including tone, strength, soft tissue length, joint alignment, and sensory changes 1

Mandatory Initial Imaging

Never skip imaging with pain this severe. Radiography is the preferred initial study and must include specific views:

• Three-view minimum: AP views in internal and external rotation PLUS axillary or scapula-Y view 1, 2, 3
• Critical caveat: AP views alone miss dislocations—axillary or scapula-Y views are vital as acromioclavicular and glenohumeral dislocations can be misclassified on AP views alone 1, 2, 3
• Perform upright, not supine: Shoulder malalignment is underrepresented on supine radiography 1, 2, 3

Immediate Pain Management

While awaiting imaging results, provide analgesia:

• First-line: Acetaminophen or ibuprofen if no contraindications 1, 2
• FDA considerations for ibuprofen: Monitor for GI symptoms (epigastric pain, dyspepsia, melena), avoid in aspirin-sensitive asthma, and use caution with coagulation disorders or anticoagulant therapy 4

Triage Based on Imaging Results

If Fracture or Dislocation Present:

Urgent surgical referral is required for: 1, 3

• Unstable or significantly displaced fractures
• Joint instability
• Glenohumeral or acromioclavicular dislocations

Conservative management can be attempted for: 1

• Most soft-tissue injuries (labral tears, rotator cuff tears)
• Stable, minimally displaced fractures

If Radiographs Are Normal:

Consider advanced imaging based on clinical suspicion:

• MRI without contrast (rating 7): For suspected rotator cuff pathology in patients with optimized imaging equipment 1
• MR arthrography (rating 9): If labral tear with or without instability suspected on physical examination 1
• Ultrasound: May be considered as diagnostic tool for shoulder soft tissue injury 1

Specific Management for Non-Traumatic Severe Pain

If imaging rules out fracture/dislocation but pain persists:

• Subacromial corticosteroid injection: Use when pain is thought related to rotator cuff or bursal inflammation 1, 2
• Gentle stretching and mobilization: For pain related to range of motion limitations, focusing on external rotation and abduction 1
• Botulinum toxin injection: Consider for subscapularis and pectoralis muscles if spasticity-related pain (particularly in stroke patients) 1

Critical Pitfalls to Avoid

• Never rely on AP views alone: This misses dislocations and is the most common imaging error 1, 2, 3
• Avoid overhead pulley exercises: These are not recommended and may worsen shoulder pain 1
• Don't inject tendons directly: Peribursal or intraarticular steroid infiltration is acceptable, but injections into the tendon or frequent repetitive injections are contraindicated 5
• Don't delay surgical referral for massive rotator cuff tears: Delaying treatment may lead to suboptimal functional outcomes 3