What is the best course of action for a patient experiencing neck and shoulder pain that improves with movement and worsens with rest?

Neck and Shoulder Pain That Improves with Movement and Worsens with Rest

This presentation is highly atypical for most shoulder pathology and suggests either inflammatory arthropathy, early adhesive capsulitis, or referred pain from cervical spine pathology—you should prioritize active range of motion exercises and early mobilization while ruling out inflammatory causes.

Key Diagnostic Considerations

The pattern described—pain improving with movement and worsening with rest—is the opposite of typical mechanical shoulder pathology, which usually worsens with activity. This clinical presentation warrants specific attention:

Critical Red Flags to Assess

• Rule out inflammatory arthropathy (rheumatoid arthritis, polymyalgia rheumatica) which characteristically improves with movement and worsens with rest 1
• Assess for early adhesive capsulitis (frozen shoulder), which develops in up to 72% of patients with prolonged immobilization and presents with progressive stiffness that paradoxically feels worse at rest 2, 3
• Evaluate cervical spine involvement, as neck pathology frequently refers pain to the shoulder region—over 80% of practitioners examine the neck when patients present with shoulder pain 4, 5
• Look for painful arc between 60-120° of abduction, which is pathognomonic for subacromial pathology (rotator cuff or bursal inflammation) 3

Essential Physical Examination Elements

• Assess muscle tone, strength, soft tissue length changes, joint alignment of the shoulder girdle, and pain levels 2, 6
• Perform neck active range-of-movement testing (used by 95.3% of practitioners) and neurological examination to identify cervical radiculopathy 4
• Test for impingement signs with attention to whether pain refers to the neck, as shoulder impingement can present as neck pain near the superomedial scapula 7
• Evaluate for signs of instability including pain during movement, decreased velocity or precision of movement, and sensations of clicking/displacement 6

First-Line Management Strategy

Immediate Therapeutic Approach

Active mobilization is mandatory and takes absolute priority—static positioning or delayed mobilization leads to adhesive capsulitis in up to 72% of cases 2, 3. The evidence consistently supports:

• Initiate range of motion exercises immediately: gentle stretching and mobilization focusing on increasing external rotation and abduction 2, 8, 6
• Progress active range of motion gradually in conjunction with restoring alignment and strengthening weak scapular girdle muscles 2, 8, 6
• Perform exercises with the upper limb in various safe positions within the patient's visual field 6
• Use gross rather than fine movements initially, as these require less concentration and are easier to control 2

Pain Management

• Start with acetaminophen or ibuprofen if no contraindications exist 2, 8, 6
• Avoid opioids or use cautiously for the shortest period possible—they should not be used routinely 8
• Consider subacromial corticosteroid injection if pain is thought related to rotator cuff or bursal inflammation, though long-term benefits remain unverified 2, 8

When Conservative Management Fails

Interventional Options (After 3-4 Weeks Without Improvement)

• Suprascapular nerve blocks are superior to placebo in reducing shoulder pain for up to 12 weeks 2, 8
• Botulinum toxin injections into subscapularis and pectoralis muscles can treat pain related to spasticity, though results are mixed for general shoulder pain 2, 8, 6
• Neuromuscular electrical stimulation (NMES) may be considered for shoulder pain 2, 6

Imaging Strategy

• Avoid routine imaging unless specific criteria are met: suspected serious pathology, failed conservative care after 3-4 weeks, or acute trauma 8, 3
• If imaging is needed, obtain upright three-view radiographs (AP internal/external rotation plus axillary or scapula-Y view) as the first study 8, 3
• Ultrasound can be used as a diagnostic tool for shoulder soft tissue injury 2, 6

Critical Pitfalls to Avoid

• Do not immobilize or delay mobilization—this is the single most important error that leads to frozen shoulder 2, 3
• Do not use manual therapy alone—it must be part of multimodal treatment including active exercise 8
• Do not overlook psychosocial factors—assess mood, anxiety, and recovery expectations as these impact outcomes 8
• Do not miss inflammatory arthropathy—morning stiffness lasting >30 minutes that improves with activity suggests systemic inflammatory disease requiring different management 1

Referral Indications

• Refer to rehabilitation specialist if cervical dystonia, neuropathy, or significant shoulder dysfunction is identified 2, 6
• Consider specialist referral after 3-4 weeks if no improvement with conservative management 3
• Immediate referral if unstable fractures or joint instability are identified on imaging 8, 3