How should I manage today a 26‑year‑old woman with acute sharp pain over the superior aspect of one shoulder and a history of prior corticosteroid injections for this problem?

Management of Recurrent Acute Shoulder Pain in a Young Woman

For a 26-year-old woman with recurrent sharp superior shoulder pain and prior steroid injections, perform a focused musculoskeletal examination today to identify the specific pain source (subacromial vs glenohumeral pathology), then consider repeating a corticosteroid injection ONLY if she achieved ≥50% pain relief lasting at least 2 months from her previous injection. 1, 2

Immediate Clinical Assessment Required

Perform a targeted examination focusing on:

• Impingement testing (Neer and Hawkins signs) to identify subacromial pathology 3
• Rotator cuff strength testing (empty can test and external rotation) to assess for tears 4
• Range of motion assessment (both active and passive) to distinguish between rotator cuff disease and adhesive capsulitis 4
• Acromioclavicular joint tenderness and cross-body adduction test for AC joint pathology 4
• Sensory testing of the shoulder region to identify any neuropathic pain component 5

The location "upper side" suggests either subacromial impingement or AC joint pathology rather than glenohumeral disease 4.

Decision Algorithm for Repeat Steroid Injection Today

Proceed with injection IF:

• Previous injection provided ≥50% pain relief for at least 2 months 1, 2
• Pain significantly interferes with function or sleep 2
• Examination confirms subacromial or bursal inflammation (positive impingement signs without evidence of complete rotator cuff tear) 2, 3

Do NOT inject IF:

• Previous injections provided minimal or short-lived benefit (<2 months) 1, 2
• Examination suggests complete rotator cuff tear (positive clinical decision rule: pain with overhead activity + weakness on empty can/external rotation + positive impingement) 4
• Multiple prior injections without sustained benefit 3

Injection Technique and Dosing

If proceeding with injection:

• Subacromial injection is preferred for superior shoulder pain related to rotator cuff or bursal inflammation 2, 3
• Use triamcinolone 20-40 mg or equivalent corticosteroid with local anesthetic 3, 6
• Ultrasound-guided injection is superior to blind injection (mean VAS improvement 34.9 vs 7.1, p<0.001) 6
• Expect short-term benefit up to 6 weeks most consistently 2

Critical Post-Injection Instructions

Absolutely avoid overhead pulley exercises after injection—they encourage uncontrolled abduction and worsen shoulder pathology 1, 2. Instead, prescribe a supervised home rehabilitation program focusing on controlled range of motion exercises 3.

When Injection is NOT Appropriate

If she does not meet criteria for repeat injection, alternative management includes:

• NSAIDs combined with structured exercise program for rotator cuff-related symptoms 5
• Ultrasound evaluation to identify specific soft tissue pathology (partial vs complete tears, bursitis) 5, 6
• Referral for surgical evaluation if no improvement after appropriate conservative measures, as 8-9% of patients with persistent symptoms have rotator cuff tears requiring surgery 3

Evidence Quality Note

The evidence for corticosteroid injections in young patients with recurrent shoulder pain is mixed. The American Academy of Orthopaedic Surgeons cannot definitively recommend for or against subacromial injections for rotator cuff pathology 5, 2. However, observational data shows 88-91% satisfaction rates at one year for appropriately selected patients with subacromial impingement 3. The key is patient selection based on prior response and accurate anatomic localization of pathology 1, 2, 6.