What are the best ways to manage severe shoulder pain?

Management of Severe Shoulder Pain

Start with ibuprofen 400 mg every 4-6 hours combined with immediate gentle range-of-motion exercises focusing on external rotation and abduction—this dual approach addresses both pain control and prevents the catastrophic complication of adhesive capsulitis that occurs in up to 72% of immobilized shoulders. 1, 2

Immediate First Steps (Day 1)

Pain Control

• Prescribe ibuprofen 400 mg every 4-6 hours as needed for pain relief 3
• Ibuprofen taken before bedtime specifically improves sleep quality and is superior to acetaminophen for rotator cuff-related pain 1
• Use the lowest effective dose for the shortest duration; doses above 400 mg show no additional analgesic benefit 3
• Apply ice before each exercise session for symptomatic relief 1

Critical Physical Examination Findings

• Look for a painful arc between 60-120° of abduction/flexion—this is pathognomonic for subacromial pathology (rotator cuff or bursal inflammation) 1
• Assess muscle tone, strength, soft tissue changes, joint alignment of the shoulder girdle, and pain levels 4, 1
• Normal rotator cuff strength rules out full-thickness tear 1

Imaging Decision

• Obtain upright three-view radiographs (AP internal/external rotation plus axillary or scapula-Y view) immediately if trauma is involved 2
• The axillary or scapula-Y views are essential—dislocations are frequently missed on AP views alone 2
• Reserve MRI for cases where conservative management fails after 3-4 weeks 2

First-Line Treatment Protocol (Weeks 1-3)

Exercise Prescription (Mandatory to Prevent Frozen Shoulder)

• Begin gentle passive and active-assisted range of motion exercises immediately, placing the arm in safe positions within the patient's visual field 4, 1
• Focus specifically on external rotation and abduction movements to address the impingement mechanism 4, 1
• Increase active range of motion gradually while simultaneously restoring proper shoulder alignment and strengthening weak muscles in the shoulder girdle 4, 1
• Early mobilization is mandatory—static positioning or delayed mobilization leads to adhesive capsulitis (frozen shoulder) in up to 72% of patients with prolonged immobilization 4, 2

Critical Pitfall to Avoid

• Never allow the patient to sleep on the affected shoulder 1
• Avoid static positioning or strapping of the upper extremity, as evidence for preventing loss of range of motion or pain is not well established 4, 1

Progression Phase (Weeks 4-8)

• Advance to intensive strengthening exercises targeting rotator cuff and scapular stabilizers 1
• Emphasize posterior shoulder musculature strengthening and address any scapular dyskinesis 1
• Implement a graduated return to overhead activities with proper mechanics 1

Adjunctive Interventions When First-Line Fails

Corticosteroid Injection

• Use subacromial corticosteroid injection when pain is clearly related to rotator cuff or bursa inflammation 4, 1
• This is appropriate when conservative management with NSAIDs and exercises has not provided adequate relief 4

Botulinum Toxin (Specific Indication)

• Inject botulinum toxin into the subscapularis and pectoralis muscles if shoulder pain is thought to be related to spasticity (typically in hemiplegic or post-stroke patients) 4

Advanced Imaging

• Obtain ultrasound evaluation to assess for structural pathology if not improving after 3-4 weeks 1
• MR arthrography is the gold standard when soft-tissue injury is suspected, superior to noncontrast MRI for diagnosing labral tears and partial rotator cuff tears 2

When to Refer to Orthopedic Surgery

• If no improvement after 3-4 weeks of conservative management, consider advanced imaging and specialist referral 1, 2
• Unstable or significantly displaced fractures require acute surgical management 2
• Joint instability (glenohumeral or acromioclavicular dislocation) typically requires acute surgical treatment 2
• Traumatic massive rotator cuff tears may require expedited surgical timeline to achieve optimal postoperative functional outcomes 2

Special Consideration: Complex Regional Pain Syndrome (CRPS/Shoulder-Hand Syndrome)

Diagnosis

• Diagnose based on pain and tenderness of metacarpophalangeal and proximal interphalangeal joints, associated with edema over the dorsum of fingers, trophic skin changes, hyperaesthesia, and limited range of motion 4
• Triple phase bone scan demonstrates increased periarticular uptake in distal upper extremity joints 4

Treatment

• Start oral corticosteroids at 30-50 mg daily for 3-5 days, then taper over 1-2 weeks to reduce swelling and pain 4
• Active, active-assisted, or passive range of motion exercises prevent CRPS development 4

Key Safety Warnings for NSAIDs

• Increased risk of bleeding, ulcers, and gastrointestinal perforation—risk increases with longer use, higher doses, smoking, alcohol, older age, and concurrent use of corticosteroids or anticoagulants 3
• Do not use after 30 weeks of pregnancy; monitor if used between 20-30 weeks 3
• Avoid in patients with history of asthma attack or allergic reaction to aspirin or other NSAIDs 3