What is the best course of management for a patient with 2 months of cervical paraspinal tenderness and anterior and posterior right shoulder pain, who has full range of motion (ROM), no swelling, and was previously treated with triamcinolone (triamcinolone) intramuscularly (IM) 6 weeks ago?

Management of Persistent Cervical and Shoulder Pain After Failed Corticosteroid Therapy

Immediate Diagnostic Workup Required

Given the failure of intramuscular triamcinolone at 6 weeks and persistent symptoms at 2 months, you should obtain three-view shoulder radiographs (AP in internal and external rotation plus axillary or scapula-Y view) and consider MRI to evaluate for cervical radiculopathy, rotator cuff pathology, or labral injury that may require surgical intervention. 1, 2

Critical Imaging Considerations

• Standard shoulder radiographs are mandatory to rule out fracture, dislocation, or significant bony pathology that may have been missed initially 1, 2
• The axillary or scapula-Y view is essential because glenohumeral dislocations are frequently missed on AP views alone 1, 2
• MRI is indicated at this point since symptoms have persisted beyond 6 weeks despite appropriate conservative management including corticosteroid injection 1
• MRI will evaluate for rotator cuff tears, labral pathology, or other soft tissue injuries requiring surgical intervention 1

Cervical Spine Evaluation is Critical

• Cervical spine pathology can refer pain to the shoulder and must be ruled out given the paraspinal tenderness 3, 4, 5
• Cervical radiculopathy is most prevalent in persons 50-54 years of age and commonly presents with neck and shoulder pain together 6, 7
• The Spurling test, shoulder abduction test, and upper limb tension test should be performed to confirm or exclude cervical radiculopathy 6
• If cervical radiculopathy is suspected based on examination, cervical spine imaging should be obtained 6, 7

Revised Conservative Management Strategy

Pain Management Options

Since the IM triamcinolone failed to provide lasting relief, consider subacromial or glenohumeral corticosteroid injection if imaging confirms rotator cuff or bursal inflammation without surgical pathology 1

• Suprascapular nerve blocks may be superior to repeat corticosteroid injections, providing pain relief for up to 12 weeks 8, 9
• Non-opioid analgesics (acetaminophen or ibuprofen) should be used if no contraindications exist 1, 2
• For neuropathic pain components (if cervical radiculopathy is confirmed), neuromodulating pain medications are reasonable 9

Physical Therapy Protocol

Initiate structured physical therapy focusing on cervical spine mobilization and shoulder strengthening 1, 4

• Begin with gentle stretching and mobilization techniques, specifically targeting external rotation and abduction 1, 2
• Critical pitfall to avoid: Do NOT use overhead pulleys, as they encourage uncontrolled abduction and can worsen shoulder pathology 9, 1
• Progress to rotator cuff and scapular stabilizer strengthening exercises 1, 2
• If cervical spine involvement is confirmed, joint mobilization directed at the impaired cervical spine segment should be included 4
• Apply ice, heat, and soft tissue massage for pain relief 9, 1

Adjunctive Therapies

• Neuromuscular electrical stimulation (NMES) may be considered for persistent shoulder pain 9, 1
• If spasticity is present, botulinum toxin injections into shoulder muscles can reduce pain associated with spasticity-related restrictions 8, 9

Surgical Referral Criteria

Refer for surgical evaluation if there is no improvement after 3-4 weeks of this revised conservative management 2

Specific Indications for Surgery

• Unstable or significantly displaced fractures on radiographs require acute surgical management 1, 2
• Massive rotator cuff tears may require expedited surgical repair for optimal functional outcomes 1
• Labral tears in the context of recurrent instability may require surgical stabilization 9
• Symptomatic cervical radiculopathy with persistent symptoms despite 4-6 weeks of conservative treatment may benefit from anterior cervical decompression 8, 6

Common Pitfalls in This Clinical Scenario

• Never rely on AP radiographs alone - dislocations are frequently missed without axillary or scapula-Y views 2
• Do not assume the shoulder is the primary problem - cervical spine pathology commonly refers pain to the shoulder and can coexist with primary shoulder pathology 3, 5
• Prolonged immobilization causes adhesive capsulitis in up to 72% of cases, so maintain gentle range of motion exercises throughout treatment 2
• The fact that full ROM is preserved suggests this may be primarily a cervical or neurogenic problem rather than intrinsic shoulder pathology 6, 4

Duration Expectations

• Conservative treatment typically requires 1-3 months depending on injury severity 1
• However, given that 2 months have already passed with one failed intervention, the threshold for advanced imaging and surgical consultation should be lower 1, 2