Management of Shoulder Pain

Initial Assessment and Imaging

The American College of Radiology recommends starting with plain radiographs, including anteroposterior views in internal and external rotation plus either an axillary or scapular-Y view, to rule out fracture, dislocation, or arthritis 1, 2, 3
Radiographs will identify fractures, glenohumeral or AC joint dislocation, and other structural abnormalities 1, 2

The American College of Radiology suggests performing a focused physical examination, including painful arc between 60-120° of abduction/flexion, rotator cuff strength testing, and passive range of motion in all planes 4, 5
The American College of Radiology recommends prescribing ibuprofen taken before bedtime, rather than acetaminophen, for rotator cuff-related pain and improving sleep quality 4
Gentle passive and active-assisted range-of-motion exercises, focusing on external rotation and abduction movements, should be started immediately 4, 5, 6

Early mobilization is mandatory to prevent development of adhesive capsulitis (frozen shoulder), which is particularly common in women over 50 years 5, 4
If no improvement after 3-4 weeks of conservative management, consider ultrasound evaluation, subacromial corticosteroid injection, MRI without contrast, or specialist referral to orthopedics 1, 4, 3, 5

Never use overhead pulley exercises, as they may worsen impingement 7
Avoid static positioning or strapping of the upper extremity, as evidence for preventing pain or loss of range of motion is not well established 7, 4
Do not delay mobilization, as early movement is essential to prevent frozen shoulder 5, 4

NSAID therapy (including ibuprofen) in patients with shoulder pain carries comparable risks of worsening kidney function in those with renal disease, development or exacerbation of hypertension, heart failure, and gastrointestinal ulceration or bleeding, as reported in the Mayo Clinic Proceedings review of NSAID safety. 8

Tenderness over the biceps tendon and supraspinatus is a characteristic finding in patients with medial shoulder pain suggestive of rotator‑cuff involvement. 9
A positive Neer impingement sign (pain with passive abduction of an internally rotated arm) indicates subacromial impingement related to rotator‑cuff pathology. 9

Rotator‑cuff pathology is the leading cause of shoulder‑related disability, accounting for roughly 8 % of adults with chronic shoulder pain; the prevalence of asymptomatic rotator‑cuff tears rises to about 54 % in individuals aged ≥ 60 years. 10

Medial shoulder pain frequently involves the biceps tendon or the subscapularis tendon, both situated medially within the rotator‑cuff complex and commonly injured in rotator‑cuff‑related conditions. 9

Approximately one‑third of patients demonstrate abnormal ultrasound findings, including effusion of the biceps tendon or subacromial bursa and tendinopathy of the biceps, supraspinatus, or subscapularis. 9