What is the best treatment approach for a 63-year-old male patient with chronic right shoulder pain and normal range of motion (ROM)?

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, a subacromial corticosteroid injection is the most appropriate initial treatment, followed by physical therapy focusing on gentle stretching and mobilization techniques.

Assessment and Diagnosis

Before proceeding with treatment, a thorough assessment of the painful shoulder should include:

• Evaluation of tone, strength, and changes in soft tissues
• Assessment of alignment of joints in the shoulder girdle
• Measurement of pain levels
• Examination for orthopedic changes 1

The radiographic evaluation (x-ray) you've ordered is appropriate as an initial screening tool for shoulder pain. For a complete assessment, the x-ray should include:

• Anteroposterior (AP) view
• Grashey projection (30° posterior oblique)
• Axillary lateral or scapular Y view 1

Treatment Algorithm

Step 1: Initial Management

• Intra-articular corticosteroid injection (triamcinolone) is recommended for shoulder pain related to inflammation of the subacromial region (rotator cuff or bursa) 1
• This approach is supported by evidence showing significant effects on pain reduction 1

Step 2: Physical Therapy

• Implement gentle stretching and mobilization techniques, focusing on:
  • External rotation
  • Abduction
  • Gradually increasing active range of motion 1
• Combine with strengthening exercises for weak muscles in the shoulder girdle

Step 3: Pain Management

• If no contraindications exist, recommend oral analgesics such as acetaminophen or ibuprofen for pain relief 1
• Avoid overhead pulley exercises as they can encourage uncontrolled abduction and potentially worsen symptoms 1

Step 4: Follow-up and Reassessment

• Evaluate response to treatment at the scheduled follow-up (7/25/25)
• Consider additional interventions if inadequate response:
  • Ultrasound as a diagnostic tool for soft tissue injury 1
  • MRI if symptoms persist and further evaluation is needed 1

Special Considerations

Potential Causes of Shoulder Pain in This Age Group

• Rotator cuff disorders (tendinopathy, partial tears)
• Subacromial bursitis
• Adhesive capsulitis
• Glenohumeral osteoarthritis 2

Cautions and Pitfalls

1. Avoid overhead pulleys as they can worsen symptoms by encouraging uncontrolled abduction 1
2. Monitor for Complex Regional Pain Syndrome (CRPS) which can develop as a complication and presents with:
   • Pain and tenderness of metacarpophalangeal and proximal interphalangeal joints
   • Edema over the dorsum of fingers
   • Trophic skin changes
   • Hyperesthesia 1
3. Consider diabetes and thyroid disorders as potential contributing factors, especially if symptoms suggest adhesive capsulitis 2

Evidence Quality and Considerations

The recommendation for corticosteroid injection is supported by multiple guidelines, with evidence level B according to Canadian Stroke Best Practice Recommendations 1 and similar support from American Heart Association/American Stroke Association guidelines 1.

Physical therapy with stretching and mobilization has consistent support across guidelines, with evidence showing improvements in pain and function when combined with appropriate medical management 1, 3.

For this patient with normal ROM but pain during movement, the combination of corticosteroid injection and targeted physical therapy offers the best approach for reducing pain and maintaining function while addressing the underlying inflammatory process.