What is the best course of treatment for a patient with shoulder pain that worsens when laying down, located at the top of the shoulder and back, accompanied by tingling but without significant limitation in arm movement?

Shoulder Pain Worse When Lying Down with Tingling

Start with plain radiographs (anteroposterior views in internal and external rotation plus axillary or scapula-Y view) to rule out fracture, dislocation, or bony pathology, then initiate conservative management with range of motion exercises and NSAIDs while considering cervical spine involvement given the tingling symptoms. 1, 2

Initial Diagnostic Approach

The clinical presentation suggests possible cervical spine involvement rather than isolated shoulder pathology. The combination of pain worse when lying down, tingling sensation, and preserved arm elevation points away from typical rotator cuff pathology and toward nerve-related issues. 3

Key Clinical Features to Assess

• Cervical spine narrowing can cause shoulder pain even without obvious radiculopathy - patients with painful shoulders have significantly narrower spinal canal diameters at C5-C6 (12.74-12.76 mm) compared to controls (13.60-13.79 mm). 3
• Shoulder impingement can present as neck/upper back pain - 30 of 34 patients with neck pain near the superomedial scapula had relief after subacromial injection, confirming referred pain patterns. 4
• Evaluate for tone, strength, soft tissue changes, joint alignment, and orthopedic abnormalities to differentiate between adhesive capsulitis, neuropathy, bursitis/tendonitis, or rotator cuff pathology. 2

Imaging Strategy

Radiography is the mandatory first step - obtain at least three views (AP in internal/external rotation and axillary or scapula-Y view) performed upright to properly assess alignment and rule out fracture or dislocation. 1

• Axillary or scapula-Y views are vital because glenohumeral and acromioclavicular dislocations can be missed on AP views alone. 1
• If radiographs are noncontributory and symptoms persist, consider MRI without contrast (rated 9/9) or ultrasound (rated 9/9) for soft tissue evaluation including rotator cuff, bursa, and biceps tendon. 1

First-Line Treatment

Begin conservative management immediately while awaiting imaging results:

• Range of motion exercises focusing on external rotation and abduction - increase active ROM gradually to prevent frozen shoulder. 2
• Avoid overhead pulley exercises as they encourage uncontrolled abduction and may worsen pain. 2
• NSAIDs (ibuprofen) for pain relief. 2
• Ice, heat, and soft tissue massage as adjunctive modalities. 2

Second-Line Interventions

If conservative measures fail after 2-4 weeks:

• Subacromial corticosteroid injection if pain is related to rotator cuff or bursa inflammation - this can also serve as a diagnostic test (positive response confirms subacromial pathology). 2, 4
• Intra-articular corticosteroid injection for glenohumeral joint inflammation. 2
• Shoulder strapping or sling for support if subluxation is present. 2

Critical Pitfall: Don't Miss Cervical Pathology

The tingling symptom is a red flag for cervical spine involvement. 3 Even without obvious radiculopathy or neck pain, cervical nerve root irritation can manifest as shoulder pain with paresthesias. If symptoms don't respond to shoulder-directed treatment within 4-6 weeks, cervical spine evaluation becomes essential. 3

Pain worse when lying down may indicate:

• Cervical nerve root compression exacerbated by supine positioning
• Subacromial impingement with positional inflammation
• Referred pain from cervical spine pathology 3, 4

When to Escalate Care

Consider advanced imaging (MRI) or specialist referral if:

• No improvement after 6 weeks of conservative treatment 2
• Progressive neurological symptoms develop 3
• Significant functional limitation persists despite treatment 2
• Radiographs show concerning bony abnormalities requiring further characterization 1