What is the next step in managing a patient with degenerative changes in the right AC (acromioclavicular) joint and right shoulder joint, narrowing of the subacromial space, and clinical correlation for impingement?

Management of Degenerative Changes in the Right Shoulder with Impingement

For a patient with degenerative changes in the right AC joint and shoulder joint with narrowing of the subacromial space and clinical impingement, the recommended next step is to initiate conservative management with physical therapy, NSAIDs, and activity modification before considering more invasive interventions. 1

Initial Conservative Management

Physical Therapy and Exercise

• Begin with range of motion and strengthening exercises focusing on the rotator cuff and posterior shoulder girdle muscles to improve shoulder mechanics and reduce impingement 1
• Active range of motion should be increased gradually while restoring alignment and strengthening weak muscles in the shoulder girdle 1
• Exercises should target the specific deficits identified during clinical examination, particularly addressing scapular mobility and rotator cuff function 2

Pain Management

• Start with acetaminophen as first-line oral analgesic due to its favorable safety profile 2
• If inadequate relief, use NSAIDs at the lowest effective dose for the shortest duration possible 2, 3
• Consider topical NSAIDs as they are preferred over systemic treatments for mild to moderate pain 2
• Local application of heat before exercise may be beneficial 2

Activity Modification

• Avoid activities that exacerbate symptoms, particularly overhead movements that can worsen impingement 3
• Modify daily activities to reduce stress on the shoulder joint during the healing process 1

Second-Line Interventions (if conservative management fails after 4-6 weeks)

Corticosteroid Injections

• Subacromial corticosteroid injections can be used when pain is related to inflammation of the subacromial region (rotator cuff or bursa) 1
• Intra-articular injection of long-acting corticosteroid may be effective for painful flares 2

Advanced Imaging

• If symptoms persist despite conservative management, MRI shoulder without contrast is appropriate to further evaluate the extent of rotator cuff pathology, labral tears, and other soft tissue abnormalities 1
• MRI can detect several abnormalities associated with shoulder impingement syndrome including subacromial bursitis, supraspinatus tendinitis, and rotator cuff tears 4
• Ultrasound is an alternative to MRI for evaluating the rotator cuff and biceps tendon, depending on local expertise 1

Surgical Considerations (if conservative measures fail after 3-6 months)

Indications for Surgical Referral

• Persistent pain and functional limitation despite adequate conservative management 1
• Evidence of significant rotator cuff tear on imaging that correlates with clinical symptoms 1
• Severe degenerative changes affecting quality of life and not responding to non-operative treatment 1

Surgical Options

• Arthroscopic subacromial decompression to increase the subacromial space by removing the anterior edge of the acromion, coracoacromial ligament, and/or acromioclavicular joint spurs 5
• Rotator cuff repair if a significant tear is present 1
• AC joint resection if AC joint arthritis is a significant contributor to symptoms 1

Important Clinical Considerations

• Shoulder impingement syndrome results from structural narrowing in the subacromial space, causing painful entrapment of soft tissues during arm elevation 3
• The presence of a bony spur projecting from the superior aspect of the acromion is a common finding in impingement syndrome and may require surgical intervention if conservative management fails 4, 6
• Conservative treatment yields satisfactory results within 2 years in approximately 60% of cases 3
• Proper positioning of the shoulder during rehabilitation is essential to prevent further impingement and promote healing 1
• The shape of the acromion (flat, curved, or hooked) may influence the development and severity of impingement syndrome 6

Common Pitfalls to Avoid

• Failing to obtain proper radiographic views (AP views in internal and external rotation and an axillary or scapula-Y view) when evaluating shoulder pain 1
• Overlooking other potential causes of shoulder pain such as cervical radiculopathy, glenohumeral instability, or internal derangement 2, 3
• Rushing to surgical intervention before an adequate trial of conservative management 3
• Not addressing scapular dyskinesis, which can contribute to impingement symptoms 1
• Neglecting to evaluate and treat contributing factors such as poor posture or muscle imbalances 2