What is the recommended management for a patient with chronic shoulder pain, limited by nighttime exacerbation, positive cross-arm test, and pain on overhead movements, despite having full range of motion?

Management of Chronic Shoulder Pain with Nighttime Exacerbation and Positive Cross-Arm Test

This patient has clinical findings consistent with acromioclavicular (AC) joint pathology and/or rotator cuff impingement, and should be initially treated with NSAIDs, activity modification, and a trial of physical therapy focused on rotator cuff strengthening and scapular stabilization, with consideration for subacromial or AC joint corticosteroid injection if conservative measures fail after 4-6 weeks. 1, 2

Clinical Diagnosis

The presentation strongly suggests AC joint pathology and/or rotator cuff impingement based on:

• Positive cross-arm test indicates AC joint involvement 3
• Pain with overhead reaching is characteristic of rotator cuff impingement 3
• Severe nighttime pain (10/10) is a hallmark of rotator cuff disorders 1, 3
• Full range of motion with pain suggests rotator cuff tendinopathy or partial tear rather than adhesive capsulitis, which would show restricted passive ROM 3
• Two-month duration qualifies this as chronic shoulder pain requiring structured management 3

Initial Conservative Management (First 4-6 Weeks)

Pharmacologic Treatment

• Start NSAIDs (e.g., ibuprofen 400-600mg three times daily) for anti-inflammatory effect and pain control 1, 2
• Consider acetaminophen as an adjunct for nighttime pain relief 4
• Avoid centrally acting analgesics that may impair function 1

Activity Modification

• Avoid overhead activities and positions that reproduce impingement (forward elevation above 90 degrees) 5
• Temporarily discontinue weightlifting that exacerbates symptoms 2
• Modify daily activities to minimize AC joint stress 2

Physical Therapy

The American Academy of Orthopaedic Surgeons recommends exercise programs for rotator cuff-related symptoms without full-thickness tears 1

Physical therapy should focus on:

• Rotator cuff strengthening exercises (external rotation, empty can test position exercises) 1, 2
• Scapular stabilization exercises to restore proper shoulder mechanics 4, 2
• Gentle range of motion exercises progressing from passive to active-assisted to active 4
• Gradual progression as pain improves 1, 2

Imaging Considerations

Plain radiographs of the shoulder should be obtained initially to evaluate for:

• AC joint arthritis 1, 3
• Calcific tendinitis 3
• Massive rotator cuff tears (superior humeral head migration) 3
• Glenohumeral arthritis 3

If diagnosis remains unclear or symptoms persist despite 6-12 weeks of conservative treatment, consider MRI without contrast to evaluate for:

• Rotator cuff tears (partial or full-thickness) 3
• Labral pathology 3
• Other soft tissue abnormalities 1

Corticosteroid Injection (If Conservative Measures Fail)

After 4-6 weeks of failed conservative treatment, consider diagnostic and therapeutic injection 2:

AC Joint Injection

• Indicated if cross-arm test remains positive and superior shoulder tenderness persists 3
• Combine corticosteroid with local anesthetic 2
• Can be performed without imaging guidance 2

Subacromial Injection

• Indicated if impingement signs predominate 2, 6
• Evidence shows conflicting results for rotator cuff tears, but may provide short-term benefit 1
• Consider ultrasound guidance for accuracy 6

Important caveat: The AAOS guidelines note inconclusive evidence for subacromial injections in rotator cuff tears, with concerns about potential adverse effects on tendon biology 1. However, for symptomatic relief in patients failing conservative therapy, a single injection trial is reasonable 2.

Referral to Orthopedics

Refer to orthopedic surgery if:

• Symptoms persist or worsen after 6-12 weeks of directed conservative treatment 2
• Significant functional impairment despite maximal conservative therapy 1
• MRI reveals full-thickness rotator cuff tear with persistent symptoms 1
• Patient desires surgical evaluation for chronic symptomatic tear 1

Key Clinical Pitfalls

• Do not assume full ROM excludes significant pathology - rotator cuff tendinopathy and partial tears can present with preserved motion 3
• Nighttime pain severity (10/10) warrants aggressive initial management - this is a red flag for rotator cuff pathology 1, 3
• The positive cross-arm test specifically localizes to AC joint - ensure injection targets the correct structure if performed 3
• Avoid multiple corticosteroid injections without orthopedic consultation due to concerns about tendon integrity 1
• Two-month duration with functional limitation (stopped working out) indicates need for structured intervention, not just reassurance 1, 2