Shoulder Pain

Soft tissue disorders of the shoulder (shoulder pain) include grade I to II sprains or strains, nonspecific shoulder pain, shoulder tendinitis, impingement syndromes, bursitis, partial thickness tears, shoulder osteoarthritis, and other soft tissue injuries of the shoulder

Shoulder pain in this guideline excludes major pathology (e.g., fractures, dislocations, infections, neoplasms, systemic disease and others), full thickness tears of the rotator cuff and biceps tendon, and frozen shoulder

Focused examination

1. Patient History 

  • Assess level of concern for major structural or other pathologies. If required, refer to an appropriate healthcare provider.

  • Identify and assess other conditions and co-morbidities. Manage using appropriate care pathways.

  • Address prognostic factors that may delay recovery.

Major structural or other pathologies may be suspected with certain signs and symptoms (red flags) including:

  • Unexplained deformity or swelling or erythema of the skin, significant weakness not due to pain, history of malignancy, suspected malignancy (e.g., weight loss or loss of appetite), fever/chills/malaise, significant unexplained sensory/motor deficits of the upper extremity, pulmonary or vascular compromise, inability to perform any movements of the shoulder, shoulder pain at rest

Examples of other conditions/co-morbidities:

  • Physical conditions: back pain, headache

  • Psychological symptoms: depression, anxiety

  • Co-morbidities: diabetes, heart disease

Examples of prognostic factors that may delay recovery:

  • Symptoms of depression or anxiety, passive coping strategies, job dissatisfaction, high self-reported disability levels, disputed compensation claims, somatization

2. Physical Examination

  • Assess levels of concern regarding major structural or other pathologies.

  • Assess for neurological signs.

3. Management 

  • Offer information on nature, management, and the course of shoulder pain. See patient handouts for more information to provide to patients.

  • Discuss the range of effective interventions with the patient and, together, select a therapeutic intervention.

Patient Handouts

CCGI_shoulder pain_patient handout_ENG.jpg
CCGI_shoulder pain_patient handout_FR.jpg
 

Management of recent-onset (≤3 months symptom duration) shoulder pain

 

Provide structured patient education (advice to stay active, reassurance, promote and facilitate return to work and normal activities, self-care advice) and any of the following therapeutic interventions*:

  • Consider cervicothoracic spine manipulation and mobilization for shoulder pain with associated pain or restricted movement of the cervicothoracic spine

  • Consider thoracic spine manipulation

  • Consider low-level laser therapy

  • Consider multimodal careᶧ that includes the combination of heat/cold, joint mobilization, range of motion exercise

  • Do not offer diacutaneous fibrolysis, ultrasound, taping, interferential current therapy, soft-tissue massage, or cervicothoracic spine manipulation and mobilization as an adjunct to exercise (i.e., range of motion, strengthening and stretching exercise) for shoulder pain (defined as pain between the neck and the elbow at rest during movement of the arm)

Management of persistent (>3 months symptom duration) shoulder pain

Provide structured patient education (advice to stay active, reassurance, promote and facilitate return to work and normal activities, self-care advice) and any of the following therapeutic interventions*:

  • Consider home-based strengthening and stretching exercises with supervision

  • Consider cervicothoracic spine manipulation and mobilization for shoulder pain with associated pain or restricted movement of the cervicothoracic spine

  • Consider thoracic spine manipulation

  • Consider low-level laser therapy

  • Consider laser acupuncture

  • Consider general physician care (including information, advice, and pharmacological pain management, if necessary)

  • Consider multimodal careᶧ that includes the combination of heat/cold, mobilization, and range of motion exercises

  • Do not offer diacutaneous fibrolysis, ultrasound, taping, interferential current therapy, soft-tissue massage, or cervicothoracic spine manipulation and mobilization as an adjunct to exercise (i.e., range of motion, strengthening and stretching exercise) for shoulder pain (defined as pain between the neck and the elbow at rest during movement of the arm), shock-wave therapy

Management of shoulder pain with calcific tendinitis 

Provide structured patient education (advice to stay active, reassurance, promote and facilitate return to work and normal activities, self-care advice) and the following therapeutic intervention*:

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

*The guideline does not include interventions for which there is a lack of evidence of effectiveness. The ordering of interventions does not reflect superiority of effectiveness
ᶧMultimodal care: treatment involving at least two distinct therapeutic modalities, provided by one or more health care disciplines

Interventions that should not be offered (Do Not Offer) provide no benefit beyond placebo/sham (i.e., statistically significant and clinically important between group differences favoring placebo/sham) or because they are harmful (i.e. serious adverse events or high frequency of minor adverse events)

Care Pathway for the management of

shoulder pain

(click here for French version)

Care pathway for the management of shoulder pain with calcific tendinitis

(click here for French version)

Exercise Videos

The shoulder pain videos are based on the recommendations from the Clinical Practice Guideline for the Management of Shoulder Pain. Select a link below to view the patient exercise videos. 

 

shoulder pain.webp

4. Reevaluation and Discharge

  • Reassess the patient at every visit to determine if: (1) additional care is necessary; (2) the condition is worsening; or (3) the patient has recovered.

  • Monitor for any emerging factors for delayed recovery.

5. Referrals and Collaboration

  • Refer the patient to a physician for further evaluation at any time during their care if they develop worsening symptoms and new physical or psychological symptoms​.