What is the management plan for a patient with degenerative changes in the shoulder joint and AC joint, relative narrowing of the subacromial space, and suspected impingement?

Management of Shoulder Degenerative Changes with Subacromial Impingement

For a patient with degenerative changes in the shoulder joint and AC joint with narrowing of the subacromial space and suspected impingement, the initial management should focus on conservative treatment including relative rest, physical therapy with specific exercises, and appropriate pain management before considering surgical options.

Initial Management

Rest and Protection

• Advise the patient to avoid painful movements, particularly overhead activities
• Apply ice for 15-20 minutes several times daily to reduce inflammation
• Protect the affected shoulder from trauma and injuries 1
• Avoid prolonged immobilization to prevent adhesive capsulitis (frozen shoulder) 1

Pain Management

1. First-line medication:

   • Acetaminophen (up to 4g/day) 1

2. Second-line options if acetaminophen is inadequate:

   • NSAIDs at lowest effective dose for shortest duration 1
   • Subacromial corticosteroid injection for inflammation in the subacromial region 1

Rehabilitation Program

Early Phase (1-2 weeks)

• Gentle active range of motion exercises after initial rest period 1
• Focus on stretching to improve range of motion, particularly external rotation and abduction 1
• Avoid overhead pulley exercises as they can worsen pain by encouraging uncontrolled abduction 1

Progressive Phase (2-6 weeks)

• Gradually increase exercise intensity 1
• Implement stretching and strengthening exercises for:
  • Rotator cuff muscles
  • Scapular stabilizers
  • Deltoid muscle
• Physical therapy with eccentric strengthening exercises 1, 2

Advanced Phase (6+ weeks)

• Progress to sport-specific or activity-specific exercises as symptoms improve 1
• Incorporate exercises that enhance neuromuscular control over the glenohumeral joint 3

Imaging Considerations

• Plain radiographs (already performed) are appropriate as first-line imaging 1
• If symptoms persist despite conservative management:
  • MRI should be considered to evaluate soft tissue pathology, particularly for biceps tendon injuries (95% sensitivity and specificity) 1
  • Ultrasound is useful for evaluating tendon pathology, showing thickening and heterogeneous echogenicity 1

When to Consider Surgical Options

• Rotator cuff repair is an option for patients with chronic, symptomatic full-thickness tears when conservative treatment fails 4
• Surgical intervention should be considered when:
  • Conservative treatments fail after adequate trial (typically 3-6 months)
  • Patient requires quick recovery
  • Prevention of tendon rupture is needed in high-risk patients 1

Special Considerations

• Degenerative changes in both the shoulder joint and AC joint suggest a more widespread pathology that may require comprehensive management
• Narrowing of the subacromial space with impingement indicates that the entire shoulder joint may be affected, not just the subacromial space 5
• Patients with subacromial impingement often have histologic and ultrastructural degenerative changes throughout the shoulder 5
• Avoid forced immobilization which can worsen stiffness 1

Follow-up Recommendations

• Evaluate pain and function every 2-4 weeks 1
• Consider shoulder strapping (sling) to prevent trauma if pain is severe 1
• If symptoms persist beyond 3 months despite conservative management, reassess and consider referral to orthopedic specialist for possible surgical intervention

Common Pitfalls to Avoid

• Prolonged immobilization leading to adhesive capsulitis
• Overhead pulley exercises that can worsen impingement symptoms
• Focusing only on the subacromial space when the entire shoulder joint may be affected
• Delaying physical therapy, which is essential for proper rehabilitation
• Relying solely on medications without implementing appropriate exercise therapy