In this article, a medical student, chief resident (orthopedic surgeon), and associate professor of orthopedic surgery at Brown University team up. Together, they review the current evidence about treatment for chronic shoulder pain. Whether it's from a rotator cuff tear, arthritis, a frozen shoulder, or a labral tear, the information in this update will guide those looking for a little help for their ongoing shoulder pain.

Of course, an accurate diagnosis is the first step. And that was the topic of a previous article in this journal back in August of 2010. Once a clear cause for the problem has been determined, then treatment can begin. Conservative (nonoperative) care is always first whenever possible.
Conservative care is made up of three things: physiotherapy, medications (usually antiinflammatory drugs), and steroid or hyaluronic injections. We will summarize each of those areas for those who are not familiar with these options.

Physiotherapy can help you regain lost shoulder motion while paying attention to your posture and alignment. Helping you change movement patterns and poor postural habits can also go a long way in preventing a relapse. You will be given a home program to follow. Cooperation with the exercises and activities recommended by the therapist will ensure a successful outcome.

Stretching exercises to increase flexibility will be followed by strengthening exercises to restore strength. The therapist will show you ways to move that will avoid impingement (pinching of the muscles and tendons around the joint).

Don't be afraid to take the medications your orthopedic surgeon or primary care physician prescribes. A simple pain reliever like acetaminophen (Tylenol) may be all that's needed to get you past the rough patch. Studies show that nonsteroidal antiinflammatory drugs (NSAIDs) can also be helpful in managing chronic shoulder pain.

Short-term use of antiinflammatories (NSAIDs) can relieve your pain without causing the terrible stomach upset and other GI problems that can occur with chronic use. Short-term refers to a couple of weeks up to a month (two to four weeks). If you do take antiinflammatories (NSAIDs) and experience any nausea, stomach pain, or other GI symptoms, tell your doctor right away. A different dose or even a different drug may be needed.

"Local therapy" is a term used to describe injections into the shoulder to reduce inflammation and pain. A numbing agent similar to novacaine combined with the steroid (antiinflammatory) can be very helpful. When local therapy is followed by physiotherapy, this treatment may be just the ticket needed to avoid surgery. This is very helpful for those patients who can't have surgery for some reason (age, poor health).

You may have heard of another type of local injection therapy called hyaluronan. These products have been used quite successfully with the knee and are being tried in the shoulder as well. The fluid that is injected into the joint helps restore the lubrication needed for smooth shoulder movement. The effect is to protect the joint surface and thereby reduce inflammation.

For some people, conservative care just doesn't do the trick. The pain continues and surgery may be recommended. The type of procedure done will depend on the underlying problem. For osteoarthritis, arthroscopic debridement is often the first step before a shoulder replacement.

The surgeon can avoid making an open incision and cutting through tendons and muscles by inserting a long thin needle into the joint. A tiny TV camera on the end of the scope allows the surgeon to see (and work) inside the joint. Any scar tissue, tears, and bone spurs are gently scraped away to restore smooth joint motion.

If there is a rotator cuff tear or degeneration, the tissue can be repaired or if necessary, reconstructed with a tissue graft. Labral and biceps tears (either alone or with rotator cuff damage) can also be repaired. The labrum is a rim of fibrous cartilage around the shoulder socket to help give it greater depth and stability. Tears of this structure can be very painful and are often severe enough to pull away with the biceps tendon still attached. That's why the repair procedure addressed both areas.

And finally, adhesive capsulitis, also known as a "frozen shoulder" -- again, the surgeon can use the arthroscope to go in and release the tight tissue. Gentle release of the fibrous tissue can be less traumatic to the shoulder than manipulation under anesthesia (MUA). Manipulation refers to moving the shoulder through its full motion while stretching and tearing the tissues that have become bound down.

In summary, the results of conservative care for chronic shoulder pain from all causes are good in the majority of people. For those who try but fail to improve with nonoperative care, surgery may be needed. Outcomes from surgery are also good to excellent in 90 per cent of the patients who go this route.

Working with a team of health care professionals including your physician and physiotherapist is your starting point. It's best not to wait too long before seeking help for that painful shoulder. Turning an acute problem away from the path of chronic pain may be as simple as a pain reliever and a few exercises. Overcoming chronic shoulder pain may be a much longer process, but it is do-able!

Reference: Michelle M. Gosselin, et al. Meeting the Challenge of Chronic Shoulder Pain: Treatment. In The Journal of Musculoskeletal Medicine. November 2010. Vol. 27. No. 11. Pp. 441-445.