What is the recommended treatment for left shoulder pain with overhead movements?

Treatment of Left Shoulder Pain with Overhead Movements

Begin with patient education on proper shoulder positioning and range of motion exercises focusing on external rotation and abduction, while strictly avoiding overhead pulley exercises. 1, 2

Initial Conservative Management

Patient Education and Positioning

• Educate patients on proper shoulder positioning and initiate both passive and active-assisted range of motion exercises, specifically emphasizing external rotation and abduction movements to prevent frozen shoulder. 2
• Use supportive devices such as slings during activities that may stress the shoulder, particularly if subluxation is present. 1
• Avoid overhead pulley exercises entirely—these encourage uncontrolled abduction and can worsen shoulder pathology and pain. 3, 1, 2

Physical Therapy Approach

• Implement gentle mobilization and stretching techniques with emphasis on external rotation and abduction to improve shoulder mobility. 2
• Progress to strengthening exercises for the rotator cuff and scapular stabilizers once acute pain is controlled. 1, 2
• Apply local heat or ice before exercise sessions for symptomatic relief. 2, 4

Pain Management Algorithm

First-Line Pharmacological Treatment

• Start with scheduled acetaminophen combined with NSAIDs or COX-2 inhibitors as the foundation for pain control. 4
• Consider topical NSAIDs for mild to moderate pain as first-line pharmacological treatment. 4

Diagnostic Assessment

• Perform a thorough musculoskeletal evaluation to identify subluxation, evaluate spasticity, and test for regional sensory changes. 1
• Use ultrasound as a diagnostic tool to identify soft tissue injuries such as rotator cuff tears, tendinopathy, or effusion. 1
• Radiography should be the initial imaging modality if structural pathology is suspected. 1

Escalation Based on Pain Characteristics

For inflammatory/structural shoulder pain:

• Consider subacromial or intra-articular corticosteroid injections when inflammation is suspected, though evidence for long-term effectiveness is limited. 1, 2, 4
• Corticosteroid injections provide significant short-term pain relief but may not improve range of motion substantially. 2

For neuropathic pain features (sensory changes, allodynia, hyperpathia):

• Trial neuromodulating pain medications such as amitriptyline 75 mg at bedtime or lamotrigine for patients with clinical signs of neuropathic pain. 3, 4
• Do not delay addressing neuropathic features—these require specific medications rather than standard analgesics alone. 4

For spasticity-related pain:

• Botulinum toxin injections into shoulder muscles (subscapularis, pectoralis major, infraspinatus) can be useful to reduce severe hypertonicity and associated pain. 3, 2
• Botulinum toxin decreases spasticity-related pain but is not sufficient for general shoulder pain reduction. 3, 1

Advanced Interventional Options

Nerve Blocks

• Suprascapular nerve blocks should be considered as an adjunctive treatment, with evidence showing effectiveness for up to 12 weeks. 3, 1, 2, 4
• Suprascapular nerve blocks are superior to placebo and as effective as glenohumeral corticosteroid injections for shoulder pain. 3

Neuromuscular Electrical Stimulation

• Consider neuromuscular electrical stimulation (NMES) for shoulder pain, particularly intramuscular NMES which shows better tolerance and efficacy than surface NMES. 3, 1
• NMES has shown significant treatment effects favoring pain-free lateral rotation. 1

Surgical Consideration

• Surgical tenotomy of pectoralis major, latissimus dorsi, teres major, or subscapularis may be considered only for patients with severe restrictions in shoulder range of motion who have failed conservative treatment. 3, 1

Critical Pitfalls to Avoid

• Never use overhead pulley exercises—they promote uncontrolled abduction and cause further injury. 3, 1, 2
• Avoid aggressive passive range of motion exercises if done improperly, as they can cause more harm than good in the complex shoulder joint. 3, 1
• Do not delay treatment, as shoulder pain can mask motor function improvement, inhibit rehabilitation, and contribute to depression, insomnia, and reduced quality of life. 2, 4
• Recognize that corticosteroid injections provide only short-term relief and should not be relied upon as the sole treatment. 2

Evidence Quality Note

The strongest evidence supports conservative management with specific exercise protocols and avoidance of overhead movements. 5 A meta-analysis of RCTs found no significant difference between surgical and conservative treatment for shoulder impingement (Hedges's g = 0.01,95% CI -0.27 to 0.30), with moderate evidence that surgery is not more effective than active exercises for reducing pain intensity. 5