What is the best course of treatment for a patient with mild left shoulder degenerative changes, currently prescribed Flexeril (cyclobenzaprine), and when should they follow up with a provider or sports medicine specialist?

Management of Mild Left Shoulder Degenerative Changes

For mild shoulder degenerative changes without acute injury, Flexeril (cyclobenzaprine) is NOT the optimal medication choice—NSAIDs like ibuprofen or naproxen should be first-line therapy, combined with physical therapy emphasizing external rotation and abduction exercises. 1, 2

Patient Information

Understanding Your Condition

• Mild degenerative changes represent early wear-and-tear arthritis in the shoulder joint, causing pain and stiffness but not requiring surgical intervention 3
• This condition responds well to conservative treatment focusing on pain control and maintaining shoulder mobility 1

About Your Current Medication (Flexeril/Cyclobenzaprine)

• Cyclobenzaprine is FDA-approved only for acute muscle spasm associated with painful musculoskeletal conditions, not for degenerative joint disease 2
• The medication should only be used for short periods (2-3 weeks maximum) because adequate evidence for longer use does not exist 2
• Cyclobenzaprine works centrally in the brain to reduce muscle spasm, not by treating joint inflammation or degeneration 2
• Drowsiness occurs in more than 30% of patients because cyclobenzaprine blocks histamine receptors in the brain, causing sedation 2, 4
• Do not drive or operate machinery while taking this medication, and avoid alcohol or other sedating drugs 2

Recommended Treatment Plan

First-Line Therapy (What You Should Be Doing Now)

• NSAIDs (ibuprofen 400-600mg three times daily or naproxen 500mg twice daily) are the appropriate first-line medication for shoulder degenerative changes 1, 3
• Physical therapy should begin immediately, focusing specifically on:
  • External rotation exercises—this is the single most critical factor for preventing and treating shoulder pain 1, 5
  • Gentle stretching and mobilization targeting abduction movements 1
  • Gradual strengthening of rotator cuff and scapular stabilizer muscles 1
• Acetaminophen can be added for additional pain control if NSAIDs alone are insufficient 1

Physical Therapy Timeline (0-12+ Weeks)

• Initial phase (0-6 weeks): Gentle stretching, mobilization techniques, and gradual strengthening with focus on external rotation 1
• Intermediate phase (6-12 weeks): Progress to more advanced strengthening exercises for rotator cuff and scapular stabilizers, address any scapular dyskinesis 1
• Advanced phase (12+ weeks): Return to sport/work-specific activities with proper mechanics 1

Second-Line Options (If Inadequate Response After 6-8 Weeks)

• Subacromial corticosteroid injection can provide short-term pain relief when inflammation is present in the subacromial region 1
• Ultrasound-guided injections provide more accurate placement and may improve outcomes 1

Critical Actions to Avoid

• Do NOT use overhead pulley exercises—these carry the highest risk of worsening shoulder pain 6, 5
• Do NOT immobilize the shoulder with slings or wraps—this promotes frozen shoulder development 5
• Do NOT delay starting physical therapy—if not initiated by 6-8 weeks, permanent shoulder dysfunction may result 5

When to Follow Up

With Primary Care Provider

• Follow up in 2-3 weeks to reassess pain control and discuss transitioning from cyclobenzaprine to NSAIDs if not already done 2, 7
• Return sooner if you experience severe drowsiness, confusion, rapid heartbeat, or other concerning side effects from cyclobenzaprine 2

With Sports Medicine/Orthopedics

• Refer to sports medicine or orthopedic specialist if:
  • Pain persists or worsens after 6-8 weeks of conservative treatment with NSAIDs and physical therapy 1
  • Significant functional limitation prevents participation in daily activities or work 1
  • Shoulder instability symptoms develop (feeling of shoulder "giving way") 1
  • Progressive weakness or inability to lift the arm develops 1

Physical Therapy Referral

• Immediate referral to physical therapy is essential—this should be arranged within 1-2 weeks of diagnosis 1, 5
• Baseline assessment should document shoulder strength, range of motion (especially external rotation), and any impingement signs 6, 1

Key Clinical Pearls

• External rotation is the most critical movement to preserve and improve—prioritize this in all exercises 1, 5
• Addressing scapular dyskinesis (abnormal shoulder blade movement) is essential for successful outcomes 1
• The entire kinetic chain including core and spine mechanics must be assessed and treated 1
• Cyclobenzaprine provides modest benefit for acute muscle spasm but is not appropriate for chronic degenerative conditions 2, 8, 9