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Shoulder pain - Management
How should I manage rotator cuff disorders?

  • Advise relative rest of the affected arm and modification of activities, including reducing precipitating movements (e.g. reaching overhead).
  • Offer analgesia: paracetamol with or without codeine, or an oral nonsteroidal anti-inflammatory drug (NSAID, e.g. ibuprofen).
    • Consider which drug has a more favourable balance of benefits and risks for the person.
    • If an oral NSAID is indicated, consider gastroprotection with a proton pump inhibitor if the person is:
      • At increased risk of gastrointestinal adverse effects.
      • Subject to dyspepsia from standard NSAIDs.
    • In people at risk of cardiovascular adverse events, ibuprofen up to 1200 mg per day or naproxen up to 1000 mg per day are recommended as first-line options.
    • If there is no early benefit from the oral NSAID, discontinue its use.
    • For more information on minimizing the risks from NSAIDs and when to consider gastroprotection, see the CKS topic on NSAIDs - prescribing issues.
  • Refer to physiotherapy if self-care measures and analgesia are not effective.
  • Consider a subacromial corticosteroid injection if the person has a poor response to initial treatment after several weeks and requires further pain relief, or has very limited function because of pain.
    • This can be done in primary care if the expertise is available, otherwise refer.
    • Discuss potential adverse effects when obtaining informed consent.
    • Although a number of steroid preparations are available, triamcinolone or methylprednisolone are the preferred option for many specialists.
    • Local anaesthetic (e.g. lidocaine) is frequently used in addition to the corticosteroid.
    • If a corticosteroid does not produce the expected benefit, the diagnosis should be reviewed.
    • Monitor people with diabetes following a steroid injection, as transient hyperglycaemia may occur for 24–48 hours.
  • Do not give a corticosteroid injection if:
    • The person has previously received a corticosteroid injection from an experienced healthcare practitioner, with minimal or no benefit.
    • The person has previously had three or more injections in the same shoulder in the course of a year.
    • A rotator cuff tear is suspected.
    • Corticosteroid injection is contraindicated (e.g. infection, sensitivity to local anaesthetic, adjacent osteomyelitis).

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