What are the recommended treatment options for shoulder pain in a patient who cannot take gabapentin?

Treatment Options for Shoulder Pain (Gabapentin Contraindicated)

Start with scheduled paracetamol (acetaminophen) combined with NSAIDs or COX-2 inhibitors as your foundation, continue this regimen throughout treatment unless contraindications exist. 1, 2, 3, 4

First-Line Pharmacological Approach

• Initiate ibuprofen taken before bedtime rather than acetaminophen alone, as this provides superior pain relief and improves sleep quality in rotator cuff-related shoulder pain 3
• Continue paracetamol and NSAID/COX-2 inhibitor combination throughout the day on a scheduled (not as-needed) basis 1, 4
• For localized pain, apply topical NSAIDs as first-line treatment for mild to moderate shoulder pain 4

Important Caveat

NSAIDs are less effective than corticosteroid injections for achieving remission at 4-6 weeks, but they avoid injection-related risks and can be combined with other modalities 5

Physical Therapy Protocol (Mandatory, Not Optional)

• Begin gentle passive and active-assisted range-of-motion exercises immediately, focusing specifically on external rotation and abduction movements to prevent frozen shoulder 2, 3, 4
• Apply local heat before exercise sessions for symptomatic relief 4
• Progress to strengthening exercises for rotator cuff and scapular stabilizers once acute pain is controlled 2

Critical Pitfall to Avoid

Never use overhead pulley exercises - they encourage uncontrolled abduction and worsen shoulder pathology 2, 3, 4

Escalation Strategy When First-Line Fails

For Inflammatory/Structural Pain (3-4 weeks without improvement):

• Subacromial or intra-articular corticosteroid injections provide superior short-term pain relief compared to NSAIDs alone 2, 4, 5
• Corticosteroid injections show significant effects on pain reduction, particularly when shoulder pathology is verified by ultrasonography 1, 2
• Consider a short course of oral corticosteroids (30-50 mg daily for 3-5 days, then taper over 1-2 weeks) if injections are not feasible 4

For Neuropathic Pain Features:

Since gabapentin is contraindicated, trial alternative neuromodulating medications 4:

• Amitriptyline 75 mg at bedtime (tricyclic antidepressant with proven efficacy for neuropathic pain) 1, 4
• Duloxetine or other SNRIs if tricyclics are not tolerated 1
• Lamotrigine as an alternative anticonvulsant option 4

Important Note: Pregabalin (gabapentin's alternative) may also be contraindicated if the patient cannot take gabapentin due to similar mechanism of action 1

For Persistent or Severe Pain:

• Suprascapular nerve blocks provide pain relief for up to 12 weeks and are specifically recommended as an adjunctive treatment 2, 4
• Botulinum toxin injections into shoulder muscles if pain is related to spasticity or severe hypertonicity 2, 4

Adjunctive Interventions

• Ice, heat, and soft tissue massage for symptomatic relief 2
• Transcutaneous electrical nerve stimulation (TENS) may provide lower pain scores at 12 hours and postoperative day 7 4
• Topical capsaicin (8% dermal patch or cream) for localized neuropathic pain - single 30-minute application provides relief for at least 12 weeks 1

Opioid Considerations

Avoid opioids as routine treatment - recent evidence demonstrates that opioid-free multimodal pathways provide superior pain relief at 12 hours, 24 hours, and 2 weeks compared to traditional opioid-containing regimens 6. The combination of scheduled NSAIDs, physical therapy, and targeted interventions (nerve blocks, corticosteroid injections) eliminates the need for opioids in most cases 1, 6.

When Opioids Are Considered:

If pain remains severe despite the above measures, opioids have questionable effectiveness (NNT 6-7 for moderate benefit) and 90% of patients experience adverse events 1. Reserve for short-term use only after optimizing all nonopioid therapies 1.

Clinical Algorithm Summary

1. Immediate initiation: Scheduled paracetamol + NSAID/COX-2 inhibitor + physical therapy (external rotation/abduction focus) 2, 3, 4
2. Week 1-2: Add topical NSAIDs for localized pain 4
3. Week 3-4 if inadequate response: Add corticosteroid injection (subacromial or intra-articular) 2, 4, 5
4. If neuropathic features present: Add amitriptyline or SNRI 1, 4
5. If still inadequate at 6-8 weeks: Consider suprascapular nerve block 2, 4
6. Throughout: Continue physical therapy, avoid overhead pulleys, prevent frozen shoulder 2, 3, 4

Key Pitfall

Do not delay addressing shoulder pain - it masks motor function improvement, inhibits rehabilitation, and contributes to depression, insomnia, and reduced quality of life 2, 4. Early aggressive multimodal treatment prevents chronicity.