Guidelines - Shoulder Pain

Scope and Purpose of Guideline

Objective: This guideline aims to promote uniform high-quality care for individuals with shoulder pain. This guideline aims to accelerate recovery, reduce the intensity of symptoms, promote early restoration of function, prevent chronic pain and disability, improve health-related quality of life, reduce recurrences, and promote active participation of patients in their care.

Target population: 

  • Individuals with shoulder pain <6 months duration

CCGI Guideline Summary

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Key Recommendations

Assessment:

  • Rule out risk factors for serious pathologies:

    • Unexplained deformity, swelling, or erythema of the skin

    • Significant weakness not due to pain

    • Past history of malignancy

    • Suspected malignancy (e.g., weight loss or loss of appetite)

    • Fever/chills/malaise

    • Significant unexplained sensory/motor deficits

    • Pulmonary or vascular compromise

    • Inability to perform any movements

    • Pain at rest

  • Conduct ongoing assessment for symptom improvement or progression during intervention and refer accordingly.

  • Discharge injured person as appropriate at any point during intervention and recovery.

Education and self-management

  • Offer information on nature, management, course of shoulder pain as a framework for initiation of a program of care.

  • Aim to understand the patient’s beliefs and expectations about shoulder pain and address any misunderstandings or apprehension through education and reassurance.

  • Educate and reassure the patient about the benign and self-limited nature of shoulder pain and reinforce the importance of maintaining activities of daily living.

Treatment: For recent-onset shoulder pain (≤3 months’ duration):

Based on shared-decision making between the patient and provider, any one of the following therapeutic interventions is recommended:

  • Low-level laser therapy for short-term pain reduction

    • Offer low-level laser therapy for short-term pain reduction (pulsed laser, 10 sessions over 2 weeks: 1) peak power = 1 kW, average power = 6 W, maximum energy of single impulse = 150 mJ, duration of single impulse <150 ms, fluency = 760 mJ/cm2, wavelength = 1064 nm; or 2) wavelength = 890 nm, time = 2 minute/point, power 2-4 j/cm2 in each point).​

  • Spinal manipulation and mobilization as an adjunct to usual care for shoulder pain with associated pain or restricted movement of the cervico-thoracic spine

  • Multimodal care that includes the combination of:

    • Heat/Cold​

    • Joint mobilization

    • Range of motion exercise

      • Daily home range of motion exercises entail progressively loaded functional movements of the arm, incorporating free weights or elastic resistance as required. Range of​ movement includes: shoulder abduction, flexion, extension, horizontal flexion and extension, hand-behind-back.

  • Interventions that are not recommended include:

    • Diacutaneous fibrolysis​

    • Ultrasound

    • Interferential current therapy

Treatment: For persistent shoulder pain (3-6 months duration):

Based on shared-decision making between the patient and provider, any one of the following therapeutic interventions is recommended:

  • Low-level laser therapy for short-term pain reduction

    • Offer low-level laser therapy for short-term pain reduction (pulsed laser, 10 sessions over 2 weeks: 1) peak power = 1 kW, average power = 6W, maximum energy of single impulse = 150mJ, duration of single impulse <150 ms, fluency = 760 mJ/cm2, wavelength = 1064 nm; or 2), wavelength = 890 nm, time - 2 minute/point, power 2-4 j/cm2 in each point).​

    • The long-term effectiveness of low-level laser therapy is unknown for sub-acromial impingement syndrome.

  • Strengthening and stretching exercises

    • Offer strengthening and stretching exercises (home-based strengthening and stretching of the rotator cuff and scapulohumeral muscles, supervised weekly for 5 weeks).​

  • Usual GP care (information, recommendation, and pain contingent medical or pharmaceutical therapy)

  • Spinal manipulation and mobilization as an adjunct to usual care for shoulder pain with associated pain or restricted movement of the cervico-thoracic spine

  • ​Supervised combined strengthening and stretching exercises:​

    • For low-grade non-specific shoulder pain, consider supervised combined strengthening and stretching exercises (8 repetitions of progressive shoulder flexion/extension/medial rotation/ lateral rotation strengthening, 2 sets, twice a week for 8 weeks; or home-based 5 repetitions of stretching of pectoralis minor and posterior shoulder per day, 10-20 repetitions of progressive strengthening for rotator cuff and serratus anterior, 3 sets per week for 8 weeks).​

  • Multimodal care that includes the combination of (if not previously given in 1st 3 months of care):

    • Heat/Cold​

    • Joint mobilization

    • Range of motion exercise

  • Interventions that are not recommended include:

    • Diacutaneous fibrolysis​

    • Shock-wave therapy

    • Cervical mobilizations (alone)

    • Multimodal care that includes the combination of exercise, mobilization, taping, psychological interventions and massage

    • Ultrasound

    • Interferential current therapy

Treatment: For recent-onset shoulder pain with calcific tendonitis (≤3 months’ duration):

Based on shared-decision making between the patient and provider, the following therapeutic interventions is recommended:

  • Shock-wave therapy with an amplitude ranging from 0.08mJ/mm2-0.06mJ/mm2

 
 
 
 
 

Referrals and Collaborations

 
  • Patients with worsening of symptoms and those who develop new physical, mental or psychological symptoms should be referred to a physician for further evaluation at any time point during their care.

  • Patients who have not significantly improved or recovered should be referred to the physician for further evaluation.

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CCGI is funded by provincial associations and regulatory boards, and national associations including the Canadian Chiropractic Association

and Canadian Chiropractic Protective Association. CCGI maintains editorial independence from funders.

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