From the Guidelines
The most likely diagnosis for this 55-year-old male is rotator cuff tendinopathy or impingement syndrome, and the next steps should include obtaining shoulder radiographs to rule out bony abnormalities and an MRI to evaluate the rotator cuff and surrounding structures, as recommended by the American College of Radiology 1. The patient's symptoms of pain along the inferior and posterior deltoid, reproducible with abduction past 90 degrees and internal rotation, are consistent with subacromial impingement, where the rotator cuff tendons become compressed between the humeral head and acromion during these movements 1. Initial treatment should consist of a 2-4 week course of NSAIDs such as ibuprofen 400-600mg three times daily or naproxen 500mg twice daily, along with physical therapy focusing on rotator cuff strengthening and scapular stabilization exercises, as these interventions have been shown to be effective in managing rotator cuff tendinopathy 1. Some key points to consider in the evaluation and management of this patient include:
- The importance of radiography in evaluating acute shoulder pain, particularly in identifying fractures or other bony abnormalities 1
- The role of MRI in evaluating the rotator cuff and surrounding structures, particularly in cases where conservative management fails 1
- The potential benefits of subacromial corticosteroid injections in managing persistent symptoms, although this should be considered only after a trial of conservative management 1
- The need for activity modification to avoid painful movements and reduce the risk of further injury or exacerbation of symptoms 1
From the Research
Possible Diagnosis
- Rotator cuff lesions or tears, given the location of pain along the inferior and posterior deltoid, and pain reproducibility with abduction past 90 degrees and internal rotation 2, 3, 4
- The patient's symptoms and physical exam findings suggest a possible rotator cuff injury, which is a common cause of shoulder pain in adults 3
Next Steps in Evaluation
- Imaging studies such as ultrasound or MRI to confirm the diagnosis and evaluate the extent of the rotator cuff injury 3, 4
- Ultrasound may be a good initial imaging modality due to its low cost and convenience, but MRI may be more accurate for evaluating the characteristics of rotator cuff tears, particularly for larger tears 4
- A thorough physical exam and medical history to rule out other possible causes of shoulder pain 2, 3
Treatment Options
- Conservative management with physical therapy and rehabilitation protocols tailored to the phase of tendon healing 5
- Injections such as corticosteroids or platelet-rich plasma (PRP) may be considered for pain management and to promote healing 2, 6
- Surgical intervention may be necessary for more severe rotator cuff tears or for patients who do not respond to conservative management 3, 6