Shoulder Pain

young women neck and shoulder pain injury, healthcare and medica

Treatment Options

1 = Least Favorable     5 = Most Favorable

R = Risk      E = Effectiveness      S = Self-Care

C = Cost     U = Usefulness (overall rating)

R

E

S

C

U

(overall rating)

Hot & Cold Packs

 5 

 2 

 5 

 5 

5

Laser

5

3

0

4

3

Manual Therapy

5

3

0

5

3

Medication NSAIDS

2

3

5

4

3

Electrical Stimulation

5

2

4

5

3

Acupuncture

5

1

0

4

2

Injections

1

2

0

1

1

Ultrasound

3

3

0

1

4

Surgery

3

3

0

1

4

What Is Shoulder Pain?

Shoulder pain is extremely common in our society. In fact it is the third most common self-reported injury according to recent literature. [i] There are several common causes of shoulder pain which include (but are not limited to):

  • Shoulder sprain/strain
  • Bursitis
  • Rotator Cuff Injury
  • Osteoarthritis
  • Frozen Shoulder Syndrome

There are a variety of treatments available in healthcare to address these common conditions. Proper diagnosis is critical to determine the best course of treatment so be sure to consult your doctor if shoulder pain persists. While mild to moderate shoulder pain may be self-limiting and resolve with time, whether it is treated or not, ongoing shoulder pain (beyond 4 weeks) should be evaluated with proper diagnostic tests (ex. xray, MRI). It is a generally accepted principle in healthcare that in order to prevent the development of chronic pain one must adequately address the pain when in the acute state. Therefore, do not hesitate to contact a healthcare provider if pain persists beyond a few weeks.

[i] Schuh-Renner et al. Accuracy of self-reported injuries compared to medical record data.

Musculoskelet Sci Pract. 2019 Feb;39:39-44. doi: 10.1016/j.msksp.2018.11.007. Epub 2018 Nov 19.

What is a Shoulder Sprain/Strain?

The two terms are often used as one even though the tissues affected are vastly different.

Sprain: In general, a “sprain” is related to the connective tissue around the joints and involves stretching or tearing of the tissue/ligament, secondary to some sort of trauma or overuse. Ligaments connect bones together while tendons connect the muscle to bone. Both ligaments and tendons are associated with poor blood supply, thus the healing time associated with injury to these tissues is rather slow and often incomplete, often leading to chronic pain and arthritis later in life. It is generally accepted that sprains range in severity from Grade 1 (a few fibers are torn) to Grade 3 (completely torn tissue)

Strain: In general, a “strain” is related to the muscles, which are very vascular (good blood supply), thus healing normally takes place in a shorter period, and healing is typically more complete.

There are a variety of treatments which can be used to treat sprain/strain of the shoulder with include but is not limited to the following:

  • Hot and Cold packs
  • Laser
  • Manual Therapy: Extremity Manipulation/Mobilization
  • Medication/NSAIDs
  • Electrical Stimulation/TENS/ultrasound
  • Acupuncture
  • Injections

The rating chart above is provided to find the treatments you may want to consider in order of their overall effectiveness.

Bursitis

Bursitis is a condition caused by inflammation of the bursa. The “bursa” is a sac located between tissues in the shoulder which reduces friction when moving the shoulder. The most common bursa in the shoulder to become inflamed is the subacromial bursa leading to “Subacromial bursitis”. The subacromial bursa separates numerous shoulder ligaments from deep tissue muscles. The subacromial bursa helps the motion of the shoulder so you can engage in common activities related to overhead work (ex. painting, cleaning windows, etc.) Regardless of the cause there are a variety of treatments to address the correction of and pain associated with bursitis. Many non-operative treatments include, but are not limited to:

  • rest
  • NSAIDs
  • Manual therapy: mobilization/extremity manipulation
  • local modalities such as cryotherapy, ultrasound, electromagnetic radiation, laser
  • subacromial injection of corticosteroids
  • physio-taping to reposition the head of the humerus
  • therapeutic exercise
  • In rare cases, surgery, for patients who do not respond to conservative care.

Normally bursitis responds favorably to conservative care but may require a variety of treatment options mentioned above. Please refer to the summary chart [hot link to summary chart above] at the beginning of this section to help you find the treatments you may want to consider in order of their overall rating. 

Rotator Cuff Injury

The “rotator cuff” is NOT a specific muscle or tissue. A rotator cuff tear is an injury to one or more of the tendons or muscles of the rotator cuff of the shoulder, which may include: Suprasupinatus, infrasupnatus, teres minor, subscapularis. Symptoms of a RTC tear may include: shoulder pain, reduced and painful movement, or weakness. [i]

What Causes Rotator Cuff Tears?

RTC tears may occur as the result of an acute injury, or may be chronic, developing over a period of time secondary to age, overuse and common activities of daily living/work, or as a result of participating in sporting activities.

Similar to bursitis, treatment may include but is not limited to the following:

  • rest
  • NSAIDs
  • Manual therapy: mobilization/extremity manipulation
  • local modalities such as cryotherapy, ultrasound, electromagnetic radiation, laser
  • subacromial injection of corticosteroids
  • physio-taping
  • therapeutic exercise
  • Surgery, for patients who do not respond to conservative care.

Please refer to the summary chart [hot link to summary chart above] at the beginning of this section to help you find the treatments you may want to consider in order of their overall rating.

Osteoarthritis

Osteoarthritis (OA) is a type of joint disease that occurs when joint cartilage breaks down gradually over time. Symptoms may include joint pain and stiffness, a grinding sensation, and eventually reduced or limitation of motion. In early stages there may be no pain at all. A simple plain film x-ray is normally all that is required to identify the presence and severity of osteoarthritis of the shoulder.

OA can develop over time secondary to overuse activity (ex. physical stress of a job, sports, etc.) causing mechanical irritation of the joint. It can also be associated with genetics or associated with past trauma. Osteoarthritis, the most common form of arthritis, affects about 237 million (3.3% of the population) people globally.

Frozen Shoulder Syndrome (FS)

Frozen shoulder syndrome (FS) is a frustrating condition to experience or treat. FS is often referred to as adhesive capsulitis and is commonly associated with extreme stiffness and pain in the shoulder joint due to the connective tissue surrounding the shoulder joint becoming inflamed and stiff, greatly restricting motion. FS syndrome can lead to significant chronic shoulder pain. Pain is usually constant. It is often worse at night leading to sleep deprivation, and also worse with cold weather. Movement of any kind can cause additional pain and cramping. The condition often develops after suffering injury or trauma or non-related conditions which result in lack of shoulder movement as they recover. Examples include recovery from stroke or heart attack. The longer one goes without movement, the greater the chances of developing FS. This condition can also lead to depression, pain in the neck and back, lack of concentration and weight loss secondary to loss of sleep, and inability to engage in common activities of daily living due to pain. With time and proper treatment most people regain about 90% of shoulder motion.

The normal course of a frozen shoulder has been described as having three stages:

Stage one: The "freezing" or painful stage. This stage could extend over six weeks to nine months and be associated with a slow onset of pain. As the experiences worsening pain the shoulder loses motion.

Stage two: During the "frozen" or adhesive stage the patient may experience a slow reduction in pain, but the stiffness remains. This stage could last from four to nine months.

Stage three: During the "thawing" or recovery stage the patient may experience an improvement in shoulder motion. While some patients may respond without treatment over time, many require significant intervention to recover from this troubling condition. Recovery could take from 6 months to 2 years.

According to recent literature manual therapy and a specific exercise program can produce clinically meaningful changes related to shoulder range of motion, pain, disability and muscle strength. [ii]

Treatment: Typical management of FS syndrome/adhesive capsulitis includes non-surgical options including but not limited to the following:

  • Joint mobilization to restore movement to the joint.
  • Manipulation under anesthesia (MUA)
  • Analgesics to control/reduce pain. (e.g., acetaminophen, nonsteroidal anti-inflammatory drugs, prednisone or other corticosteriods)
  • Massage therapy
  • Injections
  • Exercise
  • Ice/heat
  • Electrical stimulation
  • One promising treatment of FSS is Ultrasound-guided pulsed radiofrequency (UGPRF). According to literature published in January 2019 UGPRF may benefit for patients with FSS after 12 weeks treatment. [iii] [iv]

In the worst cases surgery may be required if the patient is not responding to conservative care options. Please refer to the summary chart [hot link to summary chart above] at the beginning of this section to help you find the treatments you may want to consider in order of their overall rating.

[i] Eisenberg. "Treatment Options for Rotator Cuff Tears: A Guide for Adults". Center for Clinical Decisions and Communications, Science (2005).

[ii] Dueñas et al. A 12-Week Tailored Manual Therapy and Home Stretching Program Based on Level of Irritability and Range of Motion Impairments in Patients With Primary Frozen Shoulder Contracture Syndrome: A Case Series With 9-Months Follow-Up.

J Orthop Sports Phys Ther. 2019 Jan 18:1-24. doi: 10.2519/jospt.2019.8194. [Epub ahead of print]

[iii] Yan et al. A randomized controlled trial of ultrasound-guided pulsed radiofrequency for patients with frozen shoulder. Medicine (Baltimore). 2019 Jan;98(1):e13917. doi: 10.1097/MD.0000000000013917.

[iv] Wu et al. Ultrasound-guided pulsed radiofrequency stimulation of the suprascapular nerve for adhesive capsulitis: a prospective, randomized, controlled trial. Anesth Analg. 2014 Sep;119(3):686-92. doi: 10.1213/ANE.0000000000000354.

[1] Schuh-Renner et al. Accuracy of self-reported injuries compared to medical record data.

Musculoskelet Sci Pract. 2019 Feb;39:39-44. doi: 10.1016/j.msksp.2018.11.007. Epub 2018 Nov 19.

[1] Bergman GJ, Winters JC, Groenier KH, Pool JJ, Meyboom-de Jong B, Postema K, van der Heijden GJ. Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and pain: a randomized, controlled trial. Ann Intern Med. 2004 Sep 21;141(6):432-9.

[1] Michener LA, Walsworth MK, Burnet EN. Effectiveness of rehabilitation for patients with subacromial impingement syndrome: a systematic review. J Hand Ther. 2004 Apr-Jun;17(2):152-64.

[1] Verhagen AP, Karels C, Bierma-Zeinstra SM, Burdorf L, Feleus A, Dahaghin S, de Vet HC, Koes BW. Ergonomic and physiotherapeutic interventions for treating work-related complaints of the arm, neck or shoulder in adults. Cochrane Database Syst Rev. 2006 Jul 19;(3):CD003471.

[1] Brantingham JW, Cassa TK, Bonnefin D, Jensen M, Globe G, Hicks M, Korporaal C. Manipulative therapy for shoulder pain and disorders: expansion of a systematic review. J Manipulative Physiol Ther. 2011 Jun;34(5):314-46.

[1] Rossi P, Di Lorenzo G, Faroni J, Malpezzi MG, Cesarino F, Nappi G. Use of complementary and alternative medicine by patients with chronic tension-type shoulder pain-sprain/strain: results of a shoulder pain-sprain/strain clinic survey. Shoulder pain-sprain/strain. 2006 Apr; 46(4):622-31.

[1] Garcia JD, Arnold S, Tetley K, Voight K, Frank RA. Mobilization and Manipulation of the Cervical Spine in Patients with Cervicogenic Shoulder pain-sprain/strain: Any Scientific Evidence? Frontiers in Neurology. 2016;7:40. doi:10.3389/fneur.2016.00040.

[1] Espí-López GV1, Zurriaga-Llorens R, Monzani L, Falla D.The effect of manipulation plus massage therapy versus massage therapy alone in people with tension-type shoulder pain-sprain/strain. A randomized controlled clinical trial. Eur J Phys Rehabil Med. 2016 Oct;52(5):606-617. Epub 2016 Mar 18.

[1] Aleksander Chaibi, Michael Bjørn Russell. Manual therapies for primary chronic shoulder pain-sprain/strain: a systematic review of randomized controlled trials. The Journal of Shoulder pain-sprain/strain and Pain201415:67 https://doi.org/10.1186/1129-2377-15-67

[1] Bryans R1, Descarreaux M, Duranleau M, Marcoux H, Potter B, Ruegg R, Shaw L, Watkin R, White E.Evidence-based guidelines for the chiropractic treatment of adults with shoulder pain-sprain/strain. J Manipulative Physiol Ther. 2011 Jun;34(5):274-89. doi: 10.1016/j.jmpt.2011.04.008.

[1] Garcia JD1, Arnold S1, Tetley K1, Voight K1, Frank RA1. Front Neurol.Mobilization and Manipulation of the Cervical Spine in Patients with Cervicogenic Shoulder pain-sprain/strain: Any Scientific Evidence? 2016 Mar 21;7:40. doi: 10.3389/fneur.2016.00040. eCollection 2016.

[1] Lozano López C, Mesa Jiménez J, de la Hoz Aizpurúa JL, Pareja Grande J, Fernández de Las Peñas C. Neurologia. Efficacy of manual therapy in the treatment of tension-type shoulder pain-sprain/strain. A systematic review from 2000-2013. 2014 May 21. pii: S0213-4853(14)00011-5.

[1] Castien RF1, van der Windt DA, Grooten A, Dekker J. Cephalalgia. Effectiveness of manual therapy for chronic tension-type shoulder pain-sprain/strain: a pragmatic, randomised, clinical trial. 2011 Jan;31(2):133-43. doi: 10.1177/0333102410377362. Epub 2010 Jul 20.

[1] Haldeman S, Carey P, Townsend M, Papadopoulos C. Arterial dissections following cervical manipulation: the chiropractic experience. CMAJ: Canadian Medical Association Journal. 2001;165(7):905-906.

[1] Tuby H1, Hertzberg E, Maltz L, Oron U. Long-term safety of low-level laser therapy at different power densities and single or multiple applications to the bone marrow in mice. Photomed Laser Surg. 2013 Jun;31(6):269-73. doi: 10.1089/pho.2012.3395. Epub 2013 May 15.

[1] Jimenez JJ1, Wikramanayake TC, Bergfeld W, Hordinsky M, Hickman JG, Hamblin MR, Schachner LA., Efficacy and safety of a low-level laser device in the treatment of male and female pattern hair loss: a multicenter, randomized, sham device-controlled, double-blind study. Am J Clin Dermatol. 2014 Apr;15(2):115-27. doi: 10.1007/s40257-013-0060-6.

[1] Tomaz de Magalhães M, Núñez SC, Kato IT, Ribeiro MS. Light therapy modulates serotonin levels and blood flow in women with shoulder pain-sprain/strain. A preliminary study. Experimental Biology and Medicine. 2016;241(1):40-45. doi:10.1177/1535370215596383.

[1] Gottschling S, Meyer S, Gribova I, et al. : Laser acupuncture in children with shoulder pain-sprain/strain: a double-blind, randomized, bicenter, placebo-controlled trial. Pain. 2008;137(2):405–12. 10.1016/j.pain.2007.10.004 [PubMed] [Cross Ref] F1000

[1] White PF, Elvir Lazo OL, Galeas L, Cao X. Use of electroanalgesia and laser therapies as alternatives to opioids for acute and chronic pain management. F1000Research. 2017;6:2161. doi:10.12688/f1000research.12324.1.

[1] Lanas A, Perez-Aisa MA, Feu F, Ponce J, Saperas E, Santolaria S wt al. A nationwide study of mortality associated with hospital admission due to severe gastrointestinal events and those associated with nonsteroidal antiinflammatory drug use. Am J Gastroenterol. 2005 Aug;100(8):1685-93

[1] http://www.fda.gov/ohrms/dockets/ac/02/briefing/3882B2_02_McNeil-NSAID.htm

[1] Fine M. Quantifying the impact of NSAID-associated adverse events. The American Journal of Managed Care [01 Nov 2013, 19(14 Suppl):s267-72

[1] Chou, R. Pharmacological management of low back pain. Drugs. 2010 Mar 5;70(4):387-402.

[1] Wolfe MM, Lichtenstein DR, Singh G. Gastrointestinal toxicity of non-steroidal anti-inflammatory drugs. N Engl J Med. 2007;147(7):478-491.

[1] Hawk C. The Praeger Handbook of Chiropractic Health Care.Santa Barabara CA: ABC-CLIO; 2017.

[1] Philadelphia Panel. Philadelphia Panel evidence-based clinical practice guidelines on selected rehabilitation interventions for shoulder pain. Phys Ther 2001 Oct;81(10):1719-30.

[1] Tella et al. The effect of TENS on selected symptoms in the management of patients with chronic tension type shoulder pain-sprain/strain: a preliminary study. J Hosp Med. 2008 Jan-Mar;18(1):25-9.

[1] Moshkani Farahani D et al. Comparison of Neurofeedback and Transcutaneous Electrical Nerve Stimulation Efficacy on Treatment of Primary Shoulder pain-sprain/strain: A Randomized Controlled Clinical Trial. Iranian Red Crescent Medical Journal. 2014;16(8):e17799. doi:10.5812/ircmj.17799.

[1] Physical therapy for shoulder pain-sprain/strain. César Fernández-de-las-Peñas and María L Cuadrado. Cephalalgia .Vol 36, Issue 12, pp. 1134 – 1142. First Published December 9, 2015.https://doi.org/10.1177/0333102415596445

[1] Hall et al. Effects of dry needling trigger point therapy in the shoulder region on patients with upper extremity pain and dysfunction: a systemic review with meta-analysis. Physiotherapy. 2018 June; 104(2):167-177.

[1] Babatunde OO, Jordan JL, Van der Windt DA, Hill JC, Foster NE, Protheroe J. Effective treatment options for musculoskeletal pain in primary care: A systematic overview of current evidence. PLoS One. 2017;12(6):e0178621.

[1] Skedros JG, Hunt KJ, Pitts TC. Variations in corticosteroid/anesthetic injections for painful shoulder conditions: comparisons among orthopaedic surgeons, rheumatologists, and physical medicine and primary-care physicians. BMC Musculoskelet Disord. 2007 Jul 6;8:63.

[1] Eisenberg. "Treatment Options for Rotator Cuff Tears: A Guide for Adults". Center for Clinical Decisions and Communications, Science (2005).

[1] Dueñas et al. A 12-Week Tailored Manual Therapy and Home Stretching Program Based on Level of Irritability and Range of Motion Impairments in Patients With Primary Frozen Shoulder Contracture Syndrome: A Case Series With 9-Months Follow-Up.

J Orthop Sports Phys Ther. 2019 Jan 18:1-24. doi: 10.2519/jospt.2019.8194. [Epub ahead of print]

[1] Yan et al. A randomized controlled trial of ultrasound-guided pulsed radiofrequency for patients with frozen shoulder. Medicine (Baltimore). 2019 Jan;98(1):e13917. doi: 10.1097/MD.0000000000013917.

[1] Wu et al. Ultrasound-guided pulsed radiofrequency stimulation of the suprascapular nerve for adhesive capsulitis: a prospective, randomized, controlled trial. Anesth Analg. 2014 Sep;119(3):686-92. doi: 10.1213/ANE.0000000000000354.