Conservative Management
of Shoulder Pain

Not all patients require surgery

Not all patients require surgery. Eighty percent of patients with shoulder pain will get better with non-operative treatment. In fact, only a very small percentage of patients will go on to require surgery for their shoulder. There are many conservative treatments that can effectively treat shoulder pain and restore your function and quality of life.

Physical Therapy

Physical therapy can help you decrease your shoulder pain and restore the range of motion, strength and function of the shoulder. A good physical therapy approach will be exercise-based and include a home exercise program so that frequent appointments are not necessary. The therapist may use modalities and manual therapy treatment to facilitate your patient’s recovery in addition to their exercise program. The physical therapist should incorporate these principles as the foundation for treatment.

1. Manage pain

  • Activity modification – education related to do’s and don’ts e.g. what activities and positions to avoid.
  • Work on shoulder positioning to help with pain at rest and at night.
  • Use Adjunctive treatments such as heat or ice may be helpful and taught for home use.

2. Improve/maintain shoulder mobility

The physical therapist should give your patient joint and soft tissue mobility exercises to maintain or improve their range of motion. This may include the use of a cane/stick, pulleys or stretches using the patient’s “good” arm to assist moving their affected shoulder.

3. Establish a strong, stable base of support for the arm to work from

The shoulder is a ball and socket joint. The socket, or glenoid, is part of the shoulder blade, or scapula. Many patients with shoulder pain have poor posture and poor positioning of their shoulder blades on their rib cage. This results in weakness of the muscles (scapular stabilizers) that attach the shoulder blades to the spine and move the scapula when you move your shoulder. Abnormal movement patterns of the shoulder blade are referred to as scapular dyskinesis. This abnormal movement may contribute to shoulder pain. Shoulder rehabilitation should ALWAYS include posture education and strengthening of scapular stabilizers.

In addition, spinal posture is important and directly impacts how your patient moves their shoulders. Posture correction related to the entire spine and core/lower abdominal strengthening is essential. Optimal posture and stability (using the core and scapular stabilizers) should be incorporated into all of their shoulder exercises.

4. Strengthening of the rotator cuff

The rotator cuff muscles compress and centre the ball of the shoulder in the socket during movement, providing stability to the shoulder joint. The rotator cuff initiates movement when we lift our arm, gives the ability to lift the arm above shoulder height and rotates the shoulder to reach behind our back (to tuck in a shirt or do up a bra) or up behind our head (to comb or wash our hair or pull a shirt off overhead). In addition, the rotator cuff is crucial in providing strength at shoulder height and overhead.

Pillars of Rehabilitation for Shoulder Health

Education on activity modification

Posture education

Core strengthening

Correcting faulty movement patterns

Scapular stabilization and strengthening

Rotator cuff strengthening


Shoulder injections are used for both diagnosis and treatment.
The substances most commonly injected are corticosteroids and hyaluronans.

Corticosteroid Injections

These are strong anti-inflammatory medications that help decrease swelling and inflammation. If indicated, the assessment physician will order an ultrasound-guided injection. They are often prescribed in conjunction with physical therapy to help patients have less pain with exercise and gain the mobility and strength needed to have long-term improvement of their shoulder pain. Conditions that may benefit from a corticosteroid injection include subacromial bursitis, tendinosis of the rotator cuff or biceps tendon, AC joint pathology and osteoarthritis or rheumatoid arthritis of the glenohumeral joint.

Hyaluronic Acid (HA) Injections

Hyaluronic acid (HA) is a naturally-occurring molecule that provides lubrication and cushioning in a normal joint. When a patient has osteoarthritis, the naturally-occurring HA in the fluid of their joint becomes diluted and breaks down, causing increased inflammation and arthritic change. A HA injection can be given to reduce pain and improve joint lubrication in mild to moderate arthritis of the shoulder. The effect can last 6-12 months. There is usually a cost associated with these injections, however, most private insurance covers this treatment.



Frozen shoulder, or adhesive capsulitis, is a condition characterized by stiffness and pain in the shoulder joint. Signs and symptoms usually begin gradually and worsen over time. Without treatment, most patients’ symptoms resolve in one to three years. It generally has three phases:

  1. Freezing stage – any movement causes pain and mobility starts to decrease.
  2. Frozen stage – pain starts to decrease but the shoulder becomes stiffer, limiting mobility and function.
  3. Thawing stage – the shoulder’s range of motion begins to improve.

Arthrodilation is a non-surgical intervention done by a radiologist. The radiologist injects the joint with a mixture of sterile saline, local anaesthetic and steroid. This injection stretches the joint capsule to help improve the range of motion of the shoulder joint and decrease pain in the shoulder. It is important that your patient follows up with physical therapy immediately after the procedure. Performing range of motion exercises consistently and frequently is very important for their recovery after this procedure.


Calcific tendinitis of the shoulder is caused by the deposit of calcium hydroxyapatite crystals most often inside or around the tendons of the rotator cuff. Barbotage is a procedure done under local anaesthetic. A radiologist uses an ultrasound-guided needle to break up the calcium deposits so they can be absorbed by the body. In some cases, saline fluid is injected to flush the area of the calcium particles.