Specialty Solutions Spotlight: When Shoulder Claims Stop Moving Forward

How do I know when a shoulder injury claim needs closer review?

Shoulder injuries can look routine early in a claim. But when therapy progress or return-to-work planning stalls, they can become costly and difficult to move forward. For adjusters, the key to managing these claims is knowing the red flags to watch for, why they matter and what action to take next.

Why Shoulder Claims Get Complicated

The shoulder has more range of motion than any other joint in the body, but that mobility comes with less built-in stability. Shoulder joint integrity depends on its surrounding muscles, tendons and ligaments for stabilization, and shoulder blade motion is essential for full joint mobility. When one structure is injured, the whole system can be affected.

On a claim shoulder pain may not tell the full story. An employee may start with tendon irritation, then develop stiffness, weakness, impingement or a tear if the issue is not identified and managed early. 

Red Flags to Watch For

Persistent pain after several weeks

• Watch for: Pain that remains unchanged 8 to 12 weeks after injury, treatment or surgery.
• Why it matters: Ongoing pain may point to a missed diagnosis, failed repair, nerve involvement or another complication. It can also extend treatment and delay return to work.
• What to do next: Look for updated objective findings, not just repeated pain complaints. Ask whether the provider has reassessed the diagnosis and connected symptoms to work function. Consider clinical review if the plan is not changing.

Therapy progress has plateaued

• Watch for: Little or no improvement in range of motion, strength or function across several therapy visits.
• Why it matters: A plateau can signal stiffness, poor adherence, wrong treatment intensity, an unrecognized complication or a mismatch between therapy and job demands.
• What to do next: Review therapy notes for measurable progress. Strong documentation should include active and passive range of motion, strength testing, functional limits and updated goals. If progress is unclear, ask how the plan is being adjusted.

Sudden loss of function

• Watch for: The individual was improving but suddenly loses strength, motion or ability to use the arm.
• Why it matters: A sudden decline may suggest reinjury, failed repair or nerve involvement. This is especially important after rotator cuff surgery, when a change in function may require prompt reassessment.
• What to do next: Escalate for provider review. Ask whether restrictions need to change and whether additional clinical evaluation is needed before more therapy is authorized.

Pain with overhead work

• Watch for: Difficulty reaching overhead, lifting away from the body, stocking shelves, painting, construction work or other repetitive shoulder-level tasks.
• Why it matters: Repetitive overhead work is tied to rotator cuff tendonitis, impingement and rotator cuff tears. These conditions can become progressive if untreated.
• What to do next: Confirm that job demands are documented. Look for activity modification, work restrictions and a plan to rebuild tolerance for overhead tasks.

Stiffness after immobilization or surgery

• Watch for: Increasing stiffness after sling use, surgery or a period of limited motion.
• Why it matters: Adhesive capsulitis, often called frozen shoulder, can develop after immobilization. Recovery can take 9 to 18 months, and prolonged therapy does not always speed recovery.
• What to do next: Check whether treatment matches the stage of recovery. Ask whether therapy goals are realistic and whether progress is being measured objectively.

Vague return-to-work restrictions

• Watch for: Restrictions that say “light duty” or “no use of arm” without clear limits on lifting, reaching, pushing, pulling or overhead work.
• Why it matters: Shoulder recovery depends on job demands. A desk worker, warehouse employee, construction worker and first responder may need very different return-to-work plans.
• What to do next: Ask for specific restrictions and compare them to the actual job. Consider work conditioning, ergonomic review, job site analysis or a functional capacity evaluation when physical or overhead work is required.

When to Refer to Apricus

Consider an Apricus referral to connect treatment to function with therapy coordination, additional specialty services, complementary clinical review, return-to-work support and clearer communication among the provider, employer and injured employee. When adjusters refer early, they can reduce delays, support appropriate care and keep the claim focused on safe return to work.

For more information on shoulder injuries watch our on-demand webinar Common and Complex Shoulder Injuries: Surgical Considerations and Physical Therapy Treatment and review our Common and Complex Shoulder Injury Frequently Asked Questions.

This information is meant to serve as a general overview, and any specific questions should be fully reviewed with a health care professional or specialty service provider.

To make a referral for specialty products and services, call 877.203.9899 or email apricus.referrals@enlyte.com.