What is the best course of treatment for a patient with chronic left shoulder pain and decreased range of motion for the past 6 months, with normal X-ray results and no other underlying conditions?

Chronic Left Shoulder Pain with Decreased Range of Motion

Primary Recommendation

Begin with a structured physical therapy program emphasizing gentle stretching and mobilization techniques, focusing on increasing external rotation and abduction, combined with gradual strengthening of rotator cuff and scapular stabilizers over 6-12 weeks. 1, 2

Initial Assessment Priorities

Before initiating treatment, evaluate the following specific clinical features:

• Musculoskeletal examination: Assess for focal tenderness over biceps tendon, supraspinatus, and subacromial region 3
• Spasticity evaluation: Test muscle tone throughout shoulder girdle 3
• Joint alignment: Examine scapular position and identify any dyskinesis or winging 1
• Sensory testing: Screen for regional sensory changes, allodynia, or hyperpathia that would suggest neuropathic pain 3
• Range of motion limitations: Document specific restrictions in external rotation, abduction, and internal rotation 3, 1

Consider ultrasound imaging to detect rotator cuff abnormalities (sensitivity 85%, specificity 90%) or subacromial pathology, as this can guide injection therapy decisions 1

Phase-Based Treatment Algorithm

Phase 1: Initial Conservative Treatment (0-6 weeks)

Primary interventions:

• Gentle stretching and mobilization: Focus specifically on increasing external rotation and abduction, avoiding aggressive passive range-of-motion exercises which lack supporting evidence and may cause harm 3, 2
• Gradual active range of motion: Increase movement progressively while restoring shoulder girdle alignment 3, 1
• Pain management: Use acetaminophen or ibuprofen as first-line analgesics 3, 1
• Patient education: Instruct on correct positioning and handling of the affected arm 1, 2

Strong evidence supports therapeutic exercise for reducing pain and improving function across shoulder conditions (positive effect demonstrated in meta-analysis of randomized controlled trials) 4, 5

Phase 2: Intermediate Treatment (6-12 weeks)

Progress to advanced strengthening:

• Rotator cuff strengthening: Target supraspinatus, infraspinatus, subscapularis, and teres minor 1
• Scapular stabilizer exercises: Emphasize posterior shoulder musculature to counterbalance anterior muscles 1
• Address scapular dyskinesis: Correct any winging or abnormal movement patterns through specific exercises 1, 2
• Continue flexibility work: Maintain shoulder capsule mobility 1

Combining mobilization with exercise provides additional benefit compared to exercise alone for shoulder conditions 6

Phase 3: Advanced Treatment (12+ weeks if needed)

• Functional activity progression: Return to work-specific or daily activities with proper mechanics 1
• Ensure complete symptom resolution: Before advancing to full unrestricted activity 1

Adjunctive Treatment Options

When Conservative Treatment Plateaus

Subacromial corticosteroid injection can be used when pain is related to subacromial region inflammation (rotator cuff or bursa), providing short-term pain relief to facilitate exercise therapy 3, 1

• Evidence: Superior short-term pain reduction compared to standard care, though benefits are temporary 3
• Timing: Consider if pain significantly limits participation in physical therapy 1
• Ultrasound guidance: Provides accurate placement and may improve outcomes 1

Short course of oral corticosteroids (30-50 mg daily for 3-5 days, then taper over 1-2 weeks) may reduce inflammation if present 3, 1

Alternative Modalities with Mixed Evidence

Acupuncture as adjuvant: May be safe and effective when combined with therapeutic exercise, though evidence quality is uncertain (Class IIb recommendation) 3

Avoid overhead pulley exercises: These are not recommended due to risk of traction injury to the shoulder 3, 2

Critical Pitfalls to Avoid

• Do not perform aggressive passive range-of-motion exercises: Evidence supporting this approach is missing, and improper technique can cause more harm than benefit 3, 2
• Do not overlook scapular dyskinesis: Assessment and treatment of scapular mechanics is essential for resolution 1, 2
• Do not ignore concurrent conditions: Screen for adhesive capsulitis or rotator cuff tendinopathy that may complicate treatment 1
• Avoid being overly restrictive: While maintaining appropriate precautions, allow progressive loading as tolerated 1

When to Consider Advanced Interventions

Refer for orthopedic evaluation if:

• Symptoms persist or recur after completing 12 weeks of structured physical therapy 1
• Severe restrictions in shoulder range of motion develop despite conservative treatment 3
• Clinical signs suggest structural pathology requiring surgical consideration 1

Suprascapular nerve block may be considered as adjunctive treatment, showing superiority to placebo for up to 12 weeks 3

Special Considerations

If neuropathic pain features are present (sensory changes, allodynia, hyperpathia): Consider trial of neuromodulating pain medications (Class IIa recommendation) 3

For patients with significant inflammation: A short corticosteroid course may interrupt the chronic inflammatory state and enable pain-free physical therapy 7

Therapeutic exercise demonstrates strong evidence for positive effects on pain and function across shoulder conditions, making it the cornerstone of treatment 4, 5, 6