What are the treatment options for shoulder and knee pain?

Treatment of Shoulder and Knee Pain

Knee Pain Management

Start with acetaminophen (paracetamol) up to 4g daily as first-line oral analgesic for knee pain, combined with patient education, exercise, and weight reduction if applicable. 1

Non-Pharmacological Treatment (Essential Foundation)

• Patient education about the condition, self-management strategies, and realistic expectations is mandatory for all patients 1
• Regular exercise programs including both joint-specific strengthening and aerobic conditioning reduce pain and improve function—this is evidence-based and non-negotiable 1
• Weight reduction for obese patients decreases knee osteoarthritis risk and symptoms 1
• Assistive devices such as walking sticks, knee bracing, or shoe insoles should be considered based on mechanical factors 1

Pharmacological Treatment Algorithm

First-line: Acetaminophen (paracetamol) 2600-4000mg daily in divided doses is the preferred long-term oral analgesic due to favorable safety profile (1.5% adverse events) 1

Second-line: If acetaminophen fails after adequate trial:

• Topical NSAIDs or capsaicin are safe and clinically effective 1
• Oral NSAIDs (ibuprofen up to 2400mg/day or naproxen 750mg/day) for patients unresponsive to acetaminophen 1

GI risk modification: For patients ≥60 years, history of peptic ulcer disease, GI bleeding, or concurrent corticosteroid/anticoagulant use:

• Use acetaminophen (≤4g/day), OR
• Topical NSAIDs, OR
• Oral NSAIDs plus gastroprotective agent (PPI or H2-blocker), OR
• COX-2 selective inhibitors 1

Third-line: Opioid analgesics with or without acetaminophen for patients with contraindications to NSAIDs or inadequate response 1

Adjunctive options:

• Intra-articular corticosteroid injection for acute flares, especially with effusion 1
• Glucosamine/chondroitin are NOT recommended based on best available evidence showing no clinical benefit 1

Surgical Consideration

Joint replacement should be considered for patients with radiographic evidence of knee OA who have refractory pain and disability despite optimal conservative management 1

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Shoulder Pain Management

Begin with ibuprofen 400-800mg every 6-8 hours (superior to acetaminophen for rotator cuff pain) combined with gentle range-of-motion exercises focusing on external rotation and abduction. 2, 3

Initial Diagnostic Steps

• Obtain standard shoulder radiographs (AP views in internal and external rotation plus axillary or scapula-Y view) to rule out fracture, dislocation, or bony pathology 4, 5
• Clinical assessment must evaluate muscle tone, soft tissue changes, joint alignment, pain patterns, and strength 2, 5
• A painful arc between 60-120° of abduction indicates subacromial pathology (rotator cuff or bursal inflammation) 2

Conservative Management Protocol (Weeks 1-3)

Pharmacological:

• Ibuprofen 400-800mg every 6-8 hours is superior to acetaminophen for rotator cuff-related shoulder pain, improving pain severity and functional activity 2, 3
• Take ibuprofen before bedtime to improve sleep quality 2
• Acetaminophen 500mg every 6-8 hours is an alternative but provides less functional improvement 3

Physical therapy (critical to prevent frozen shoulder):

• Start immediately with gentle passive and active-assisted range of motion exercises within the patient's visual field 4, 2, 5
• Focus specifically on external rotation and abduction movements to address impingement 4, 2, 5
• Apply ice before each exercise session for symptomatic relief 2
• NEVER use overhead pulley exercises—they encourage uncontrolled abduction and worsen pathology 1, 4, 5
• Never allow sleeping on the affected shoulder 2

Adjunctive modalities:

• Ice, heat, and soft tissue massage to reduce pain and inflammation 4, 5
• Complete rest from aggravating activities until acute symptoms resolve 4

Progression Phase (Weeks 4-8)

• Gradually increase active range of motion while restoring proper joint alignment 4, 2, 5
• Intensive strengthening of rotator cuff and scapular stabilizer muscles 4, 2
• Re-establish proper shoulder and spine mechanics 4
• Progress to dynamic stabilization exercises 4

Second-Line Interventions

Subacromial corticosteroid injection when pain is clearly related to rotator cuff or bursa inflammation—corticosteroid is more effective than NSAIDs for achieving remission at 4-6 weeks 4, 2, 5, 6

For spasticity-related shoulder pain:

• Botulinum toxin injections into subscapularis and pectoralis muscles 1, 5
• Suprascapular nerve blocks as adjunctive treatment 1, 5

Additional options:

• Neuromuscular electrical stimulation (NMES) for persistent pain 1, 4, 5
• Functional dynamic orthoses to facilitate task-specific training 4

When to Escalate Care

Obtain MRI if symptoms persist beyond 3 months despite appropriate conservative management to evaluate for rotator cuff tears, labral pathology, or soft tissue injuries requiring surgical intervention 4

Surgical tenotomy may be considered for patients with severe restrictions in shoulder range of motion 1

Critical Pitfalls to Avoid

• Early mobilization is mandatory—static positioning or delayed mobilization leads to adhesive capsulitis (frozen shoulder) 1, 2
• Overhead pulley exercises are contraindicated 1, 4, 5
• Do not return to full activities until achieving pain-free motion and adequate strength 4, 2
• Glenohumeral and acromioclavicular dislocations can be missed on AP views alone—axillary or scapula-Y views are mandatory 4, 5

Special Consideration: Knee-Shoulder Pain Connection

Persistent knee pain predicts subsequent bilateral shoulder pain, likely mediated by leg weakness causing altered biomechanics and increased upper extremity loading—addressing knee pain and leg strength may prevent shoulder pain development 7