What is the evidence-based practice (EBP) for managing a patient with right shoulder pain and tenderness?

Evidence-Based Management of Right Shoulder Pain and Tenderness

Begin with standard shoulder radiographs (AP views in internal and external rotation plus axillary or scapula-Y view) to rule out fracture or dislocation, then initiate a structured conservative management program focusing on gentle mobilization, progressive strengthening, and non-opioid pain control. 1

Initial Diagnostic Workup

Imaging Strategy

• Obtain plain radiographs as the mandatory first-line imaging study including anteroposterior views in internal and external rotation plus either axillary or scapula-Y view 1
• The axillary or scapula-Y views are critical because glenohumeral and acromioclavicular dislocations can be missed on AP views alone 1
• Avoid routine advanced imaging (MRI) unless: (1) serious pathology is suspected, (2) symptoms persist beyond 3 months of appropriate conservative care, or (3) imaging findings would change management 2, 1

Clinical Assessment

• Evaluate muscle tone, strength, soft tissue changes, alignment of the shoulder girdle joints, and pain levels 2, 1, 3
• Look for a painful arc between 60-120° of abduction/flexion, which indicates subacromial pathology (rotator cuff or bursal inflammation) 4
• Assess for psychosocial factors including mood, anxiety, depression, and recovery expectations, as these influence outcomes 2

Conservative Management Protocol (First-Line Treatment)

Phase 1: Acute Pain Control and Early Mobilization (Weeks 1-3)

Pain Management:

• Use ibuprofen as first-line analgesic (superior to acetaminophen for rotator cuff-related pain), taken before bedtime to improve sleep quality 2, 4, 3
• Acetaminophen may be considered if NSAIDs are contraindicated 2, 3
• Apply ice before each exercise session for symptomatic relief 4
• Avoid opioids unless absolutely necessary, and only for the shortest period possible with careful consideration of risks and benefits 2

Early Mobilization (Critical to Prevent Frozen Shoulder):

• Begin gentle passive and active-assisted range of motion exercises immediately, placing the arm in safe positions within the patient's visual field 1, 4, 3
• Focus specifically on increasing external rotation and abduction through gentle stretching and mobilization techniques 2, 1, 4, 3
• Critical pitfall to avoid: Do NOT use overhead pulleys, as they encourage uncontrolled abduction and can worsen shoulder pathology 1
• Complete rest from aggravating activities until acute symptoms resolve 1

Phase 2: Progressive Strengthening (Weeks 4-8)

• Gradually increase active range of motion in conjunction with restoring proper shoulder alignment 2, 1, 4, 3
• Advance to intensive strengthening exercises targeting rotator cuff and scapular stabilizer muscles 1, 4
• Emphasize posterior shoulder musculature strengthening and address any scapular dyskinesis 4
• Re-establish proper mechanics of the shoulder and spine 1
• Progress to dynamic stabilization exercises 1
• Incorporate core and lumbopelvic strengthening as part of the kinetic chain 1

Adjunctive Interventions

Consider if conservative measures alone are insufficient:

• Subacromial corticosteroid injection when pain is clearly related to rotator cuff or bursal inflammation 2, 1, 4, 3
• Botulinum toxin injections into subscapularis and pectoralis muscles if pain is related to spasticity 2, 1, 3
• Functional dynamic orthoses to facilitate repetitive task-specific training 2, 1, 3
• Neuromuscular electrical stimulation (NMES) for persistent pain 1, 3
• Repetitive transcranial magnetic stimulation (rTMS) or transcranial direct current stimulation (tDCS) as adjuncts to therapy 2, 1, 3

Manual Therapy Considerations

• If manual therapy is used, it must be applied only in conjunction with other treatments (exercise, education, activity advice), never as a stand-alone treatment 2

When Conservative Management Fails

• If symptoms persist beyond 3 months despite appropriate conservative management, obtain MRI to evaluate for rotator cuff tears, labral pathology, or other soft tissue injuries requiring surgical intervention 2, 1, 4
• For rotator cuff disorders specifically, consider surgical review if 3 months of non-surgical management has been unsuccessful 2

Critical Pitfalls to Avoid

• Never allow the patient to sleep on the affected shoulder - proper positioning during sleep is crucial 4
• Early mobilization is mandatory to prevent development of adhesive capsulitis (frozen shoulder) 4
• Avoid static positioning or strapping of the upper extremity, as evidence for preventing loss of range of motion is not well established 4
• Returning to activity too soon before adequate healing and strengthening can lead to chronic pain and dysfunction 1
• Do not use overhead pulleys during rehabilitation 1

Return to Activity

• Return to normal activities only after achieving pain-free motion and adequate strength 1
• Ensure complete resolution of symptoms before returning to full overhead activities 4
• Duration of conservative treatment typically ranges from 1-3 months depending on injury severity 1

Red Flags Requiring Urgent Evaluation

• Unstable or significantly displaced fractures require acute surgical management 1
• Joint instability with recurrent dislocation requires urgent orthopedic consultation 1
• Unexplained progression of signs and symptoms warrants imaging and specialist referral 2