What is the best approach to manage chronic right shoulder pain in a 63-year-old male patient with normal range of motion?

Management of Chronic Right Shoulder Pain in a 63-Year-Old Male

For a 63-year-old male with chronic right shoulder pain and normal range of motion, the recommended approach is radiographic imaging followed by physical therapy and intra-articular corticosteroid injection, which aligns with your current treatment plan. 1

Diagnostic Approach

Initial Imaging

1. X-ray of the right shoulder is the appropriate first-line imaging study
   • Should include at least three views:
     • Anteroposterior (AP) views in internal and external rotation
     • Axillary or scapula-Y view 1
   • Radiography provides good delineation of bony anatomy to assess for:
     • Fractures
     • Shoulder alignment
     • Acromioclavicular joint pathology
     • Glenohumeral osteoarthritis 1

When to Consider Advanced Imaging

• If x-rays are noncontributory but symptoms persist:
  • MRI without contrast is recommended for patients over 40 with suspected rotator cuff pathology
  • MR arthrography is preferred for suspected labral tears, especially in younger patients 1

Treatment Algorithm

First-Line Treatment

1. Physical Therapy

   • Focus on:
     • Gentle stretching and mobilization techniques
     • Gradually increasing external rotation and abduction
     • Strengthening weak muscles in the shoulder girdle 1
   • Should be continued for 6-12 weeks before considering more invasive options 2

2. Analgesics

   • NSAIDs or acetaminophen for pain control if no contraindications 1
   • Should be used as an adjunct to physical therapy, not as standalone treatment

Second-Line Treatment

1. Intra-articular Corticosteroid Injection
   • Particularly effective when pain is related to:
     • Subacromial inflammation
     • Rotator cuff pathology
     • Bursal inflammation 1
   • Timing: Your plan for injection on 7/25/25 is appropriate if initial conservative measures don't provide adequate relief

Treatment Considerations Based on Specific Diagnoses

• Rotator Cuff Disorders: Physical therapy + subacromial injection
• Adhesive Capsulitis: Range of motion exercises + intra-articular injection
• Acromioclavicular Osteoarthritis: Activity modification + targeted injection
• Glenohumeral Osteoarthritis: Physical therapy + intra-articular injection 2

Common Pitfalls to Avoid

1. Inadequate imaging: Failing to obtain proper radiographic views can miss significant pathology

   • Ensure axillary or scapula-Y views are included to evaluate for glenohumeral pathology 1

2. Premature injection: Providing steroid injection without a trial of physical therapy

   • Injections should generally be used as an adjunct to therapy, not as first-line treatment 2

3. Delayed referral: Failing to refer to orthopedic specialist when symptoms persist

   • Consider orthopedic referral if symptoms persist after 6-12 weeks of directed treatment 2, 3

4. Overreliance on passive treatments: Focusing solely on pain relief without addressing underlying functional deficits

   • Active rehabilitation is essential for long-term improvement 1, 3

Your current plan of x-ray, physical therapy, and scheduled intra-articular injection represents an evidence-based approach to managing this patient's chronic shoulder pain while maintaining normal range of motion.