What is the best treatment approach for a patient with neck and shoulder pain, considering their medical history and potential underlying conditions such as osteoarthritis?

Treatment of Neck and Shoulder Pain

Begin with a structured multimodal conservative program combining exercise-based physical therapy, NSAIDs or acetaminophen, and manual therapy techniques, reserving imaging and injections for patients who fail to improve after 12-16 weeks. 1, 2

Initial Assessment and Red Flags

Before initiating treatment, assess for serious pathology ("red flags") that would require imaging or specialist referral, including: 1

• Progressive neurological deficits
• Suspected fracture, infection, or malignancy
• Severe trauma history
• Constitutional symptoms (fever, unexplained weight loss)

Avoid routine radiological imaging unless red flags are present, conservative care has failed after 12-16 weeks, or findings would change management. 1

Evaluate psychosocial factors ("yellow flags") that predict poor outcomes, including depression, anxiety, catastrophizing, and poor recovery expectations, as these require integrated psychological interventions. 1

First-Line Treatment: Exercise and Physical Therapy

Exercise therapy is the cornerstone of treatment and should be initiated immediately for all patients regardless of age or comorbidities. 1, 3, 4

Physical Therapy Protocol

• Refer to physical therapy for supervised exercise program design within the first 2-4 weeks. 3, 2
• Focus on gentle stretching and mobilization techniques targeting external rotation and abduction to address impingement and prevent frozen shoulder. 2
• Progress to strengthening exercises for rotator cuff and scapular stabilizers over 12-16 weeks. 2
• Include aerobic exercise options based on patient preference: walking, aquatic exercise, resistance training, or cycling. 1
• Avoid overhead pulleys as they encourage uncontrolled movement and may worsen pain. 2

Manual therapy (mobilization techniques) should be used only in conjunction with exercise therapy, not as standalone treatment. 1 Manual therapy combined with exercise shows superior outcomes compared to continued general practitioner care alone. 5

First-Line Pharmacologic Management

Start with acetaminophen (up to 4g/24h maximum) or NSAIDs as initial pharmacologic therapy due to favorable safety profiles. 1, 3, 2

NSAID Selection and Monitoring

• Topical NSAIDs are preferred for localized shoulder or neck pain, offering pain relief with minimal systemic exposure. 1, 3
• For more widespread pain, oral NSAIDs (ibuprofen, naproxen, or celecoxib) can be used at the lowest effective dose for the shortest duration needed. 1, 6
• Use NSAIDs with caution in older adults and patients with cardiovascular disease, chronic kidney disease, or history of gastrointestinal bleeding. 1
• Celecoxib 100-200mg twice daily provides pain relief comparable to naproxen 500mg twice daily for osteoarthritis. 6
• Evaluate treatment response at 2-4 weeks; consider NSAID rotation or advance to second-line options if insufficient response. 2

Critical Medication Warnings

Do not use opioids for chronic neck and shoulder pain. 1 Guidelines consistently discourage opioid use due to lack of additional benefit over NSAIDs and significant harm potential. 1

Do not use acetaminophen as monotherapy for low back pain, but it remains appropriate for neck and shoulder osteoarthritis pain. 1, 3

Second-Line Treatment Options (After 12-16 Weeks)

Injectable Therapies

Corticosteroid injections can be considered for shoulder pain after 12-16 weeks of failed conservative management, though evidence quality is limited. 4, 2, 7

• Subacromial corticosteroid injections are appropriate when pain is thought to be related to subacromial inflammation. 2
• Glenohumeral corticosteroid injections have insufficient evidence for osteoarthritis but are widely used in clinical practice. 4, 2
• Use corticosteroid injections cautiously in athletes due to potential cartilage damage with repeated use. 4, 7

Viscosupplementation (hyaluronic acid) is an option for chronic shoulder osteoarthritis, typically administered as three weekly injections. 4, 2 Improvements in pain and function occur at 1,3, and 6 months, though evidence is limited to industry-supported studies. 4

Adjunctive Therapies

• Topical capsaicin provides localized pain relief with minimal systemic exposure for osteoarthritis. 3
• Psychological therapies (cognitive behavioral therapy, mindfulness-based stress reduction) should be integrated for patients with depression, anxiety, or poor coping skills. 1
• Acupuncture, massage, and spinal manipulation are conditional recommendations that can be added to multimodal care. 1

When to Consider Surgical Referral

Surgery should only be considered after 3-6 months (minimum 12 weeks) of failed comprehensive conservative management. 1, 2

Shoulder-Specific Surgical Considerations

For glenohumeral osteoarthritis refractory to conservative care: 4

• Total shoulder arthroplasty (TSA) is preferred over hemiarthroplasty, providing superior pain relief and functional outcomes. 4
• Do NOT perform TSA in patients with irreparable rotator cuff tears; reverse total shoulder arthroplasty should be considered instead. 4
• Avoid arthroplasty in patients under 50 years when possible due to increased risk of prosthetic loosening. 4
• Refer to surgeons performing at least 2 shoulder arthroplasties per year to reduce complications. 4

Treatment Timeline and Re-evaluation

• Evaluate initial treatment response at 2-4 weeks. 2
• Re-evaluate at 12 weeks; consider alternative approaches if no significant functional improvement. 2
• Standard rehabilitation for chronic shoulder pain requires 12-16 weeks of skilled therapy. 2
• Imaging is only indicated if there is unsatisfactory response to conservative care, unexplained progression of symptoms, or if findings would change management. 1

Common Pitfalls to Avoid

• Do not rely solely on passive treatments (injections, manual therapy alone) without exercise therapy. 1, 2
• Do not prescribe opioids for chronic musculoskeletal neck and shoulder pain. 1
• Do not order routine imaging in the absence of red flags or failed conservative care. 1
• Do not use glucosamine or chondroitin for disease modification in osteoarthritis. 1
• Do not continue ineffective treatments beyond 12-16 weeks without reassessment and treatment modification. 2