Treatment of Shoulder Strain
For acute shoulder strain, initiate immediate rest from aggravating activities, combined with NSAIDs or acetaminophen for pain control, followed by a structured physical therapy program emphasizing rotator cuff and scapular stabilizer strengthening once pain-free motion is achieved. 1
Initial Management (First 2-6 Weeks)
- Complete rest from all aggravating activities until the patient becomes asymptomatic is the cornerstone of early treatment. 1
- NSAIDs (ibuprofen, naproxen) or acetaminophen should be prescribed as first-line analgesics to provide adequate pain control and enable participation in rehabilitation. 1, 2
- Ice, heat, and soft-tissue massage can be used as adjunctive modalities for pain relief during the acute phase. 1, 2
Physical Therapy Protocol
Phase 1: Range of Motion Restoration
- Begin stretching and mobilization exercises focusing specifically on external rotation and abduction, as external rotation is the single most critical factor in preventing chronic shoulder dysfunction. 1, 2
- Avoid overhead pulley exercises entirely—this intervention carries the highest risk of worsening rotator cuff pathology and should never be used. 1, 2
Phase 2: Strengthening (Once Pain-Free Motion Achieved)
- Initiate rotator cuff strengthening exercises using eccentric loading protocols, which are specifically recommended to promote tendon healing. 1
- Include scapular stabilizer strengthening, as scapular dyskinesis contributes significantly to rotator cuff injury and must be addressed. 1
- Three exercise modalities are equally effective: open-chain resisted band exercises, closed-chain exercises, and minimally loaded range-of-motion exercises all produce significant improvements in pain and disability. 3
Escalation for Inadequate Response
If Symptoms Persist After 3-6 Weeks:
- Intra-articular or subacromial corticosteroid injection (triamcinolone) provides significant pain relief and is appropriate for more severe cases that fail initial conservative management. 1
- Important caveat: Peritendinous or intratendinous corticosteroid injections may inhibit healing and reduce tensile strength, potentially predisposing to spontaneous rupture—ensure proper injection technique targeting the joint space or subacromial bursa, not the tendon itself. 2
If Symptoms Persist After 3-6 Months:
- MRI without contrast becomes appropriate to evaluate for full-thickness rotator cuff tears or other structural pathology requiring surgical consideration. 1
- Surgical referral is reserved for the small proportion (approximately 9%) of patients who fail adequate conservative therapy over 3-6 months. 1, 4
Return to Activity Criteria
- Allow return to full activities only after completing a functional, progressive, individualized program over 1-3 months without evidence of symptoms. 1
- Premature return to aggravating activities before achieving pain-free motion and adequate strength restoration leads to recurrence and chronicity. 1
Critical Pitfalls to Avoid
- Never immobilize the shoulder with slings or wraps beyond the first few days, as this promotes adhesive capsulitis development. 2
- Never delay physical therapy initiation beyond 6-8 weeks, as this can result in permanent shoulder dysfunction. 2
- Never use overhead pulleys at any stage of rehabilitation—this is the single most harmful intervention. 1, 2
- Never inject corticosteroids directly into the tendon substance—only intra-articular or subacromial injections are appropriate. 2
Age-Specific Considerations
- For patients over 35-40 years: Focus on rotator cuff disease and degenerative changes, which are the predominant pathologies in this age group. 1
- For patients under 35 years: Consider instability and labral pathology if symptoms do not follow typical strain patterns, though these require different management approaches. 1