The guidelines developed by the New York State Workers Compensation Board are intended to aid healthcare providers in prescribing appropriate medication for shoulder injuries.
Designed for medical professionals, these Workers Compensation Board guidelines offer support in determining the right medications for individuals with shoulder injuries.
It’s important to emphasize that these guidelines do not replace clinical judgment or professional experience. The final decision on medication should be a collaborative one, involving the patient and their healthcare provider in consultation.
For most patients, ibuprofen, naproxen, or other older generation NSAIDs are recommended as first-line medications. Acetaminophen (or the analog paracetamol) may be a reasonable alternative to NSAIDs for patients who are not candidates for NSAIDs, although most evidence suggests acetaminophen is modestly less effective. There is evidence that NSAIDs are as effective for relief of pain as opioids (including tramadol) and less impairing.
Non-Steroidal Anti-inflammatory Drugs (NSAIDs) for Treatment of Acute, Subacute, or Chronic Shoulder pain:
- Recommended – for treatment of acute, subacute, or chronic shoulder pain.
- Indications: For acute, subacute, or chronic shoulder pain, NSAIDs are recommended for treatment. Over-the-counter (OTC) agents may suffice and should be tried first.
- Frequency/Duration: As needed use may be reasonable for many patients.
- Indications for Discontinuation: Resolution of symptoms, lack of efficacy, or development of adverse effects that necessitate discontinuation.
NSAIDs for Patients at High Risk of Gastrointestinal Bleeding:
- Recommended – for concomitant use of cytoprotective classes of drugs: misoprostol, sucralfate, histamine Type 2 receptor blockers, and proton pump inhibitors for patients at high risk of gastrointestinal bleeding.
- Indications: For patients with a high-risk factor profile who also have indications for NSAIDs, cytoprotective medications should be considered, particularly if longer-term treatment is contemplated. At-risk patients include those with a history of prior gastrointestinal bleeding, elderly, diabetics, and cigarette smokers.
- Frequency/Dose/Duration: Proton pump inhibitors, misoprostol, sucralfate, H2 blockers recommended. Dose and frequency per manufacturer. There is not generally believed to be substantial differences in efficacy for the prevention of gastrointestinal bleeding.
- Indications for Discontinuation: Intolerance, development of adverse effects, or discontinuation of NSAID.
NSAIDs for Patients at Risk for Cardiovascular Adverse Effects:
- Patients with known cardiovascular disease or multiple risk factors for cardiovascular disease should have the risks and benefits of NSAID therapy for pain discussed.
- Recommended – Acetaminophen or aspirin as the first-line therapy appear to be the safest regarding cardiovascular adverse effects.
- Recommended – If needed, NSAIDs that are non-selective are preferred over COX-2 specific drugs.
- In patients receiving low-dose aspirin for primary or secondary cardiovascular disease prevention, to minimize the potential for the NSAID to counteract the beneficial effects of aspirin, the NSAID should be taken at least 30 minutes after or 8 hours before the daily aspirin.
Acetaminophen for Treatment of Shoulder Pain:
- Recommended – for treatment of shoulder pain, particularly in patients with contraindications for NSAIDs.
- Indications: All patients with shoulder pain, including acute, subacute, chronic, and post-operative.
- Dose/Frequency: Per manufacturer’s recommendations; may be utilized on an as-needed basis. There is evidence of hepatic toxicity when exceeding four gm/day.
- Indications for Discontinuation: Resolution of pain, adverse effects, or intolerance.
Rationale for Recommendations: For most patients, generic ibuprofen, naproxen, or other older generation NSAIDs are recommended as first-line medications. Second-line medications should include one of the other generic medications. Acetaminophen (or the analog paracetamol) may be a reasonable alternative for these patients, although most evidence suggests acetaminophen is modestly less effective for arthrosis patients. There is evidence that NSAIDs are as effective for relief of pain as opioids (and tramadol) and less impairing.
Topical Medications
- Recommended – In select patients for the treatment of pain associated with acute, subacute, or chronic shoulder pain, including topical creams, ointments, and lidocaine patches.
Rationale for Recommendation: TOPICAL DRUG DELIVERY (e.g., capsaicin, topical lidocaine, topical NSAIDs, and topical salicylates and nonsalicylates) may be an acceptable form of treatment in selected patients. A topical agent should be prescribed with strict instructions for application and the maximum number of applications per day to obtain the desired benefit and avoid potential toxicity. For most patients, the effects of long-term use are unknown and thus may be better used episodically. These agents may be used in those patients who prefer topical treatments over oral medications. Localized skin reactions may occur, depending on the medication agent used. Prescribers should consider that topical medication can result in toxic blood levels.
Capsaicin offers a safe and effective alternative to systemic NSAIDs, although its use is limited by local stinging or burning sensation that typically disappears with regular use. Patients should be advised to apply the cream on the affected area with a plastic glove or cotton applicator to avoid inadvertent contact with eyes and mucous membranes. Long-term use of capsaicin is not recommended.
Topical Lidocaine is only indicated when there is documentation of a diagnosis of neuropathic pain. In this instance, a trial for a period of not greater than four weeks can be considered, with the need for documentation of functional gains as criteria for additional use.
Topical NSAIDs (e.g., diclofenac gel) may achieve tissue levels that are potentially therapeutic. Overall the low level of systemic absorption can be advantageous, allowing the topical use of these medications when systemic administration is relatively contraindicated (such as patients with hypertension, cardiac failure, peptic ulcer disease, or renal insufficiency).
Topical Salicylates or Nonsalicylates (e.g., methyl salicylate) overall do not appear to be more effective than topical NSAIDs. May be used for a short-term course, especially in patients with chronic conditions in whom systemic medication is relatively contraindicated or as an adjuvant to systemic medication.
Opioids:
- Not Recommended – for acute, subacute, or chronic shoulder pain.
- Recommended – for limited use (not more than seven days) for post-operative pain management as adjunctive therapy to more effective treatments.
- Indications: For post-operative pain management, a brief prescription of opioids as adjuncts to more efficacious treatments (especially NSAIDs, acetaminophen) is often required, especially nocturnally.
- Frequency/Duration: Prescribed as needed throughout the day, then later only at night, before weaning off completely.
- Rationale for Recommendation: Some patients have insufficient pain relief with NSAIDs, thus judicious use of opioids may be helpful, particularly for nocturnal use. Opioids are recommended for brief, select use in post-operative patients with primary use at night to achieve sleep post-operatively.
Hypnotics:
- Hypnotics may be given to shoulder injury sufferers because of a chief complaint of “inability to sleep.” Such medications must be used with caution because of their dependence-producing capabilities.
- Time to produce effect: 1-3 days.
- Frequency: At night.
- Optimum duration: 1 week.
- Maximum duration: 2-3 weeks.
Psychotropic/Anti-Anxiety Medications:
- Not recommended. [Note: These guidelines do recommend the use of antidepressant medications in limited circumstances, and in select patients, such as with specific nerve injuries.]
Skeletal Muscle Relaxants:
- Not Recommended.
