What is the best course of treatment for a 43-year-old male patient with chronic left shoulder pain, normal range of motion (ROM), and a history of heavy lifting and pulling, who is scheduled for an x-ray of the left shoulder?

Management of Chronic Left Shoulder Pain in a 43-Year-Old Male

For this 43-year-old male with chronic left shoulder pain likely related to rotator cuff pathology, an MRI of the shoulder without contrast should be ordered as the next diagnostic step after the planned x-ray, followed by a structured physical therapy program focusing on rotator cuff strengthening. 1

Diagnostic Approach

Initial Imaging

• Your plan to order an x-ray is appropriate as the first-line imaging study for shoulder pain
• However, plain radiographs are often non-contributory in soft tissue injuries of the shoulder 2
• If x-rays are negative (which is likely given normal ROM and deep joint pain):
  • MRI shoulder without contrast should be the next imaging study (rated 7/9 for appropriateness) 2
  • This will help identify potential rotator cuff pathology, labral tears, or other soft tissue injuries

Clinical Considerations

• The patient's history suggests a rotator cuff disorder:
  • Onset during weight training (bench press, pushups, pullups)
  • Deep, sharp pain inside the joint
  • Normal ROM (typical in early/moderate rotator cuff pathology)
• At age 43, rotator cuff disorders are more common than instability issues that predominate in younger patients 3

Treatment Plan

Immediate Management

1. NSAIDs as first-line medication rather than acetaminophen for both pain and inflammation 1

   • Consider a 2-week trial of scheduled NSAIDs (not just PRN)
   • Tylenol may be less effective for this type of inflammatory condition

2. Structured physical therapy program focusing on:

   • Eccentric strengthening exercises for the rotator cuff
   • Scapular stabilization
   • Posterior capsule stretching
   • Proper biomechanics during lifting activities 1

3. Activity modification:

   • Temporarily avoid bench press, pushups, and pullups
   • Modify workout routine to reduce overhead activities
   • Gradually reintroduce these exercises with proper form under PT guidance 1

If Initial Treatment Fails (after 4-6 weeks)

1. Consider corticosteroid injection to the subacromial space if inflammation is present

   • Limited to 2-3 injections with 4-6 weeks between injections 1

2. Reassess pain and function every 4-6 weeks

   • Adjust treatment plan if no improvement after 8-12 weeks 1

3. Consider surgical referral if:

   • Pain persists despite 3-6 months of conservative management
   • MRI shows a significant rotator cuff tear or other surgical pathology 1

Important Considerations

• Biofreeze cream can be used as adjunctive therapy but should not replace NSAIDs or structured rehabilitation
• Recovery timeline: Even with optimal management, resolution typically requires 3-6 months 1
• HCV treatment history: While not directly related to shoulder pathology, monitor liver function if prescribing NSAIDs due to potential hepatotoxicity
• Pitfall to avoid: Relying solely on passive treatments (like Biofreeze and Tylenol) without addressing the underlying biomechanical issues through proper rehabilitation

Over 90% of shoulder pain cases have good outcomes with appropriate conservative management that includes proper imaging, anti-inflammatory medication, and structured rehabilitation 1.