What is the recommended treatment approach for a patient with shoulder pain, assuming no signs of severe injury or underlying conditions?

Recommended Treatment Approach for Shoulder Pain

For patients with shoulder pain and no signs of severe injury, begin with plain radiographs (AP views in internal and external rotation plus axillary or scapula-Y view) followed by conservative management consisting of rest from aggravating activities, NSAIDs for pain control, physical therapy focused on range of motion and rotator cuff strengthening, with consideration of corticosteroid injections for persistent symptoms after 4-6 weeks. 1, 2, 3

Initial Diagnostic Imaging

Radiographs are the mandatory first step in evaluating shoulder pain, as they identify fractures, dislocations, and joint alignment issues that would alter management. 1

• Obtain three standard views: anteroposterior in internal rotation, anteroposterior in external rotation, and axillary or scapula-Y view 1, 3
• The axillary or scapula-Y view is critical because glenohumeral and acromioclavicular dislocations can be missed on AP views alone 1
• Perform radiographs in standing position, as poor shoulder alignment may be underestimated when supine 3

Conservative Management Protocol

Phase 1: Acute Pain Control (0-2 weeks)

Complete rest from all aggravating activities until the patient becomes asymptomatic. 2, 3

• Prescribe NSAIDs (ibuprofen or naproxen) as first-line pharmacological therapy for pain and inflammation 1, 4
• Acetaminophen can be used if NSAIDs are contraindicated 1
• Apply ice for acute pain and consider heat for chronic muscle tension 2

Phase 2: Restore Range of Motion (2-6 weeks)

Begin gentle stretching and mobilization techniques focusing specifically on external rotation and abduction to prevent frozen shoulder development. 1, 2, 3

• Prioritize external rotation exercises, as lateral rotation limitation is most significantly related to ongoing shoulder pain 2
• Use active, active-assisted, or passive range of motion exercises 1
• Avoid overhead pulley exercises, which encourage uncontrolled abduction and can worsen rotator cuff pathology 2, 3

Phase 3: Strengthening (6-12 weeks)

Initiate rotator cuff and scapular stabilizer strengthening only after achieving pain-free motion. 2, 3

• Focus on rotator cuff strengthening exercises 3
• Include periscapular muscle strengthening 3
• Address scapular dyskinesis, which both contributes to and results from rotator cuff pathology 2

Adjunctive Interventions

Consider corticosteroid injections if conservative measures fail after 4-6 weeks of appropriate therapy. 2, 3, 4

• Subacromial corticosteroid injections (triamcinolone) are appropriate when pain is thought to be related to subacromial impingement or rotator cuff tendinopathy 1, 2
• Intra-articular injections can be used for glenohumeral pathology 2
• These provide significant pain relief and enable participation in physical therapy 2

Functional electrical stimulation (FES) may be added to improve shoulder lateral rotation and reduce pain. 2

Shoulder strapping can serve as both preventive and therapeutic intervention. 2

When to Advance to MRI

Order MRI without contrast if conservative management fails after 6-12 weeks of appropriate physical therapy, or if clinical features suggest full-thickness rotator cuff tear. 3

Clinical features warranting earlier MRI include: 3

• Significant weakness on resisted external rotation
• Positive impingement signs
• Age >60 years with combination of above findings
• Need for surgical planning

Expected Timeline and Return to Activities

Allow return to activities after completing a functional, progressive, individualized program over 1-3 months without evidence of symptoms. 2

Long-term studies demonstrate that patients with chronic shoulder pain can expect significant decreases in pain and improvements in function after conservative treatment, regardless of whether stiffness accompanies the pain. 5

Critical Pitfalls to Avoid

Do not assume absence of trauma means absence of fracture, especially in elderly patients where osteoporotic fractures occur with minimal or unrecognized trauma. 2

Do not use overhead pulley exercises, as they promote uncontrolled abduction that worsens rotator cuff pathology. 2, 3

Do not delay imaging if there is any concern for fracture, dislocation, or severe structural injury, as these require different management pathways. 1

Surgical Referral Indications

Refer for orthopedic surgical evaluation if: 3, 6

• Conservative management fails after 3-6 months
• MRI shows full-thickness rotator cuff tear with tendon retraction, muscle atrophy, or fatty infiltration
• Unstable or significantly displaced fractures are identified
• Recurrent shoulder instability or dislocations occur