What is the best approach for managing shoulder pain in a patient?

Shoulder Pain Management

For acute traumatic shoulder pain, obtain upright three-view radiographs (AP internal/external rotation plus axillary or scapula-Y view) immediately, then initiate conservative management with NSAIDs, ice, and early mobilization for soft-tissue injuries, reserving surgery only for unstable fractures or persistent joint instability. 1

Initial Diagnostic Approach

Traumatic Shoulder Pain

• Obtain radiographs as the first imaging study with three mandatory views: anteroposterior in internal and external rotation plus an axillary or scapula-Y view 1
• Perform radiographs upright because supine positioning underrepresents shoulder malalignment 1
• The axillary or scapula-Y views are essential—acromioclavicular and glenohumeral dislocations are frequently misclassified on AP views alone 1
• Look for a painful arc between 60-120° of abduction/flexion, which is pathognomonic for subacromial pathology (rotator cuff or bursal inflammation) 2, 3
• Normal rotator cuff strength rules out full-thickness tear 2

Advanced Imaging (When Radiographs Are Indeterminate)

• CT without contrast characterizes complex fracture patterns and identifies subtle nondisplaced fractures—changes clinical management in up to 41% of proximal humeral fractures 1
• MR arthrography is the gold standard for traumatic shoulder pain when soft-tissue injury is suspected, superior to noncontrast MRI for diagnosing SLAP tears, labroligamentous injuries, and partial rotator cuff tears 1
• Reserve MRI for cases where conservative management is planned and detailed soft-tissue characterization will alter treatment decisions 1

Conservative Management Protocol

Weeks 1-3: Acute Phase

• Start gentle passive and active-assisted range of motion exercises immediately—focus specifically on external rotation and abduction to address the impingement mechanism 2, 3
• Apply ice before each exercise session for symptomatic relief and pain reduction 2, 3
• Prescribe ibuprofen 400-800 mg every 6-8 hours, taken before bedtime to improve sleep quality—ibuprofen is superior to acetaminophen for rotator cuff-related pain based on improved SPADI and Quick-DASH scores 4
• Never allow sleeping on the affected shoulder—proper positioning during sleep is crucial 2, 3
• Avoid overhead pulley exercises that may worsen pain 2

Weeks 4-8: Progression Phase

• Advance to intensive strengthening exercises targeting rotator cuff and scapular stabilizers once acute pain improves 2, 3
• Emphasize posterior shoulder musculature strengthening and address scapular dyskinesis 2, 3
• Implement a graduated return to overhead activities with emphasis on proper mechanics 2, 3
• Ensure complete resolution of symptoms before returning to full activities 2

Pharmacologic Management

• NSAIDs are first-line therapy for pain reduction and diminution of inflammation 5
• Ibuprofen provides superior improvement in pain severity and functional activity compared to acetaminophen, as measured by validated shoulder-specific outcome scores 4
• Consider oral vitamin C and vitamin D supplementation to slow cartilage degeneration in cases of glenohumeral osteoarthritis 5

Injection Therapy (Second-Line)

• Subacromial corticosteroid injection is indicated when pain is clearly related to rotator cuff or bursa inflammation and conservative measures have not provided adequate relief 2, 3
• Glenohumeral joint injections should be performed under fluoroscopic guidance 6
• The injection site (subacromial, acromioclavicular joint, or intra-articular) depends on the specific diagnosis 6

Surgical Indications

• Unstable or significantly displaced fractures require acute surgical management 1
• Joint instability (glenohumeral or acromioclavicular dislocation) typically requires acute surgical treatment 1
• Traumatic massive rotator cuff tears may require an expedited surgical timeline to achieve optimal postoperative functional outcomes 1
• Most soft-tissue injuries (labral tears, rotator cuff tears) can undergo a period of conservative management before considering surgery 1

Critical Pitfalls to Avoid

• Early mobilization is mandatory—static positioning or delayed mobilization leads to adhesive capsulitis (frozen shoulder), which occurs in up to 72% of patients with prolonged immobilization 1, 2, 3
• Do not rely on AP radiographs alone—glenohumeral and acromioclavicular dislocations are frequently missed without axillary or scapula-Y views 1
• Avoid lidocaine and high concentrations of long-acting local anesthetics in joint injections—they are chondrotoxic 7

When to Refer

• Refer to orthopedic surgery if symptoms persist or worsen after 6-12 weeks of directed conservative treatment 6
• Consider earlier referral if radiographs demonstrate unstable fractures, significant displacement, or joint instability requiring acute surgical intervention 1
• If no improvement after 3-4 weeks of conservative management, consider advanced imaging and specialist referral 3