Recurrent Shoulder Pain Despite Physical Therapy

​Chronic shoulder pain is a common problem seen in primary care and sports medicine. Shoulder pain is second only to low back pain in patients seeking care for musculoskeletal ailments in the primary care setting.

Effective therapy depends on an accurate diagnosis of the more common etiologies: rotator cuff disorders, adhesive capsulitis, acromioclavicular joint osteoarthritis, glenohumeral osteoarthritis, impingement syndrome and ligament instability. Activity modification and analgesics are the initial treatments in most cases. If this does not lead to improvement, or if the initial presentation is of sufficient severity, a trial of physical therapy that focuses on the specific diagnosis is most often the next step. Combined steroid and local anesthetic injections can be used alone or as an adjuvant to the physical therapy, but recent studies have shown these do not always prove to be a long-term solution to the problem, especially if ligament laxity, partial rotator cuff tears or pain at the attachments of ligament to bone (humerus) persists.

The site of the injection (subacromial, acromioclavicular joint, or intra-articular) depends on the diagnosis. Injections into the glenohumeral joint can be more precise with ultrasound guidance. Symptoms that persist may be candidates for prolotherapy and/or platelet rich plasma (PRP) injections.