What is the best treatment approach for a patient with shoulder pain, considering their medical history and potential pre-existing conditions like arthritis?

Shoulder Pain Treatment

Begin with standard shoulder radiographs (AP views in internal and external rotation plus axillary or scapula-Y view) to rule out fracture or dislocation, then initiate a structured conservative program combining acetaminophen or ibuprofen with progressive physical therapy focused on gentle mobilization and rotator cuff strengthening. 1

Initial Diagnostic Imaging

• Radiographs are mandatory as the first-line imaging study for any shoulder pain, particularly if trauma is involved, to identify fractures, dislocations, or bony pathology 2, 1
• The standard trauma series must include three views minimum: anteroposterior in internal and external rotation, plus either axillary or scapula-Y view 1
• Critical pitfall: Never skip the axillary or scapula-Y views, as glenohumeral and acromioclavicular dislocations are frequently missed on AP views alone 3, 1
• Perform radiographs upright rather than supine to avoid underestimating malalignment 3

Conservative Management Protocol (First-Line Treatment)

Pain Control

• Use acetaminophen or ibuprofen as first-line analgesics if no contraindications exist 3, 1
• Ibuprofen provides superior improvement in pain severity and functional activity compared to acetaminophen for rotator cuff-related pain, though acetaminophen may offer quality of life benefits 4
• For patients with arthritis-related shoulder pain, celecoxib 100 mg twice daily or 200 mg once daily provides significant pain reduction within 24-48 hours and is comparable to naproxen 500 mg twice daily 5
• Apply ice, heat, and soft tissue massage to reduce pain and inflammation 1

Subacromial Corticosteroid Injection

• Consider subacromial corticosteroid injection if pain is related to rotator cuff or bursal inflammation, either alone or as an adjuvant to physical therapy 3, 1

Physical Therapy Progression

Phase 1: Rest and Gentle Mobilization

• Complete rest from aggravating activities until acute symptoms resolve 1
• Begin with gentle stretching and mobilization techniques, focusing specifically on increasing external rotation and abduction 1
• Use active, active-assisted, or passive range of motion exercises performed in safe positions within the patient's visual field 1
• Critical pitfall: Do NOT use overhead pulleys, as they encourage uncontrolled abduction and can worsen shoulder pathology 1

Phase 2: Strengthening

• Gradually increase active range of motion in conjunction with restoring proper joint alignment 1
• Strengthen rotator cuff and scapular stabilizer muscles 1
• Re-establish proper mechanics of the shoulder and spine 1

Phase 3: Dynamic Stabilization

• Progress to dynamic stabilization exercises 1
• Incorporate core and lumbopelvic strengthening as part of the kinetic chain 1

Additional Conservative Therapies

• For shoulder pain of any duration, consider low-level laser therapy, multimodal care (heat/cold, joint mobilization, range of motion exercise), or thoracic spine manipulation 6
• For chronic shoulder pain (>3 months duration), consider stretching/strengthening exercises, laser acupuncture, or general physician care 6
• Functional dynamic orthoses may facilitate repetitive task-specific training 1
• Neuromuscular electrical stimulation (NMES) can be considered for persistent shoulder pain 1

When to Escalate Care

• If symptoms persist beyond 3 months despite appropriate conservative management, obtain MRI to evaluate for rotator cuff tears, labral pathology, or other soft tissue injuries requiring surgical intervention 1
• Massive traumatic rotator cuff tears may require expedited surgical repair for optimal functional outcomes 1
• Unstable or significantly displaced fractures require acute surgical management 1
• Joint instability with recurrent dislocation requires urgent orthopedic consultation 1

Return to Activity

• Return to normal activities only after achieving pain-free motion and adequate strength 1
• Common pitfall: Returning to activity too soon before adequate healing and strengthening leads to chronic pain and dysfunction 1
• Duration of conservative treatment typically ranges from 1-3 months depending on injury severity 1

Special Considerations for Arthritis

• For patients with underlying osteoarthritis or rheumatoid arthritis affecting the shoulder, celecoxib demonstrates significant reduction in joint pain, tenderness, and swelling 5
• Celecoxib 100 mg twice daily and 200 mg twice daily show similar effectiveness, with some patients deriving additional benefit from the higher dose 5
• A total daily dose of 200 mg can be administered as either 100 mg twice daily or 200 mg once daily with equal effectiveness 5