What is the best course of treatment for a 40-year-old with persistent pain and decreased range of motion (ROM) following a hyperextended shoulder injury?

Management of Persistent Shoulder Pain and Decreased ROM After Hyperextension Injury in a 40-Year-Old

Begin with standard shoulder radiographs (AP views in internal and external rotation plus axillary or scapula-Y view) to rule out fracture, dislocation, or significant bony pathology, followed by a structured conservative management program focusing on gentle mobilization, progressive strengthening, and pain control. 1

Initial Diagnostic Approach

Imaging Strategy

• Radiography is the mandatory first-line imaging study for any traumatic shoulder injury to identify fractures, dislocations, or malalignment 1
• The standard trauma series must include at minimum three views: anteroposterior in internal and external rotation, plus either axillary or scapula-Y view 1
• Axillary or scapula-Y views are critical because glenohumeral and acromioclavicular dislocations can be missed on AP views alone 1
• If radiographs are normal but symptoms persist, consider MRI or ultrasound to evaluate soft tissue injuries including rotator cuff tears, labral tears, or capsular injury 1, 2

Clinical Assessment

• Evaluate muscle tone, strength, soft tissue changes, joint alignment of the shoulder girdle, and pain levels 1, 3
• Specifically assess for signs of instability including pain during movement, decreased velocity or precision of movement, and sensations of popping or shifting 3, 4
• The most common limitation after shoulder injury is restricted abduction, which occurs in approximately 44% of cases 5

Conservative Management Protocol

Phase 1: Pain Control and Protection (First 2-4 Weeks)

Pain Management:

• Use non-opioid analgesics such as acetaminophen or ibuprofen if no contraindications exist 1, 3, 4, 6
• Consider subacromial corticosteroid injection if pain is thought to be related to rotator cuff or bursal inflammation 1
• Apply ice, heat, and soft tissue massage to reduce pain and inflammation 1, 4
• Complete rest from aggravating activities until acute symptoms resolve 4

Phase 2: Restore Range of Motion (Weeks 2-8)

Mobilization Strategy:

• Begin with gentle stretching and mobilization techniques, focusing specifically on increasing external rotation and abduction 1, 3, 4
• Use active, active-assisted, or passive range of motion exercises performed in safe positions within the patient's visual field 1, 3
• Critical pitfall to avoid: Do NOT use overhead pulleys, as they encourage uncontrolled abduction and can worsen shoulder pathology 1, 4
• Gradually increase active range of motion in conjunction with restoring proper joint alignment 1, 3, 4

Phase 3: Strengthening and Stabilization (Weeks 6-12)

Progressive Strengthening:

• Strengthen rotator cuff and scapular stabilizer muscles 4
• Re-establish proper mechanics of the shoulder and spine 4
• Progress to dynamic stabilization exercises 4
• Incorporate core and lumbopelvic strengthening as part of the kinetic chain 4

Adjunctive Therapies to Consider

Evidence-Based Options:

• Functional dynamic orthoses may facilitate repetitive task-specific training 1, 3
• Neuromuscular electrical stimulation (NMES) can be considered for persistent shoulder pain 3
• Repetitive transcranial magnetic stimulation (rTMS) or transcranial direct current stimulation (tDCS) may be used as adjuncts to upper extremity therapy 1, 3
• For pain related to spasticity (less common in pure trauma), botulinum toxin injections into subscapularis and pectoralis muscles can be considered 1, 3

When Conservative Management Fails

Indications for Advanced Imaging or Surgical Consultation

• If symptoms persist beyond 3 months despite appropriate conservative management, obtain MRI to evaluate for rotator cuff tears, labral pathology, or other soft tissue injuries requiring surgical intervention 1, 2
• Massive traumatic rotator cuff tears may require expedited surgical repair for optimal functional outcomes 1
• Persistent instability with recurrent subluxation events (the "dead arm" syndrome) may require surgical stabilization 7

Special Considerations for This 40-Year-Old Patient

Age-Specific Factors:

• At age 40, this patient is in the transition zone where both traumatic soft tissue injuries and early degenerative changes can coexist 2
• Adhesive capsulitis (frozen shoulder) can develop after trauma and presents with diffuse pain and restricted passive range of motion 2
• Most soft-tissue injuries can undergo a period of conservative management (typically 3 months) before considering surgery 1

Return to Activity Protocol

• Return to normal activities only after achieving pain-free motion and adequate strength 4
• Common pitfall: Returning to activity too soon before adequate healing and strengthening can lead to chronic pain and dysfunction 4
• Duration of conservative treatment typically ranges from 1-3 months depending on injury severity 4

Red Flags Requiring Urgent Evaluation

• Unstable or significantly displaced fractures require acute surgical management 1
• Joint instability with recurrent dislocation requires urgent orthopedic consultation 1
• Progressive neurologic symptoms may indicate cervical radiculopathy masquerading as shoulder pain 8