How to treat a patient with deltoid muscle pain, slight tenderness, and swelling after a reported trauma (injury) last month?

Treatment of Deltoid Muscle Pain with Tenderness and Swelling After Trauma One Month Ago

For a patient presenting with deltoid muscle pain, tenderness, and swelling one month after trauma, initiate conservative management with NSAIDs, ice therapy, relative rest with activity modification, and consider adding a muscle relaxant if muscle spasm is present, followed by progressive physical therapy once acute symptoms improve. 1, 2, 3, 4

Initial Assessment and Diagnosis

Clinical Evaluation

• Assess for chronic tendinopathy versus muscle strain: One month post-trauma suggests transition from acute injury to chronic degenerative changes, particularly if pain is load-related and localized 2
• Key physical findings to document: Well-localized tenderness on palpation that reproduces activity-related pain, swelling, asymmetry compared to contralateral side, and any limitation in range of motion 2
• Rule out serious pathology: Ensure no signs of infection (fever, erythema, warmth), compartment syndrome (severe pain out of proportion, neurovascular compromise), or fracture 5, 4

Imaging Considerations

• Initial imaging is NOT typically required for straightforward muscle strain or contusion with trauma history and normal neurovascular examination 5, 4
• Consider MRI without contrast if: Pain persists beyond 6-8 weeks of conservative treatment, clinical suspicion for rotator cuff tear, or atypical presentation requiring exclusion of focal myositis or other pathology 5, 2, 6
• Ultrasound may show: Muscle edema, tendon thickening, or heterogeneous echogenicity in tendinopathy cases 2

Treatment Algorithm

Phase 1: Acute Symptom Control (First 1-2 Weeks)

Pharmacologic Management:

• NSAIDs as first-line: Ibuprofen 400-800 mg orally three times daily with food for pain and inflammation control 3, 7, 4

  • Provides both analgesic and anti-inflammatory effects 3
  • Use lowest effective dose for shortest duration needed 3
  • Caution: Monitor for GI side effects; consider proton pump inhibitor if risk factors present 5, 3
  • Avoid in patients with cardiovascular disease, renal impairment, or history of GI bleeding 3

• Muscle relaxant if spasm present: Cyclobenzaprine 5-10 mg orally three times daily for up to 2-3 weeks as adjunct to rest and physical therapy 8

  • Indicated specifically for relief of muscle spasm associated with acute, painful musculoskeletal conditions 8
  • Should only be used for short periods (2-3 weeks maximum) 8

Physical Modalities:

• Ice therapy: Apply melting ice water through wet towel for 10-minute periods, repeated multiple times daily 1, 7
• Relative rest: Reduce but do not completely eliminate activity to prevent muscle atrophy and deconditioning 1, 9
• Avoid aggravating activities: Temporarily modify movements that reproduce pain, particularly overhead activities for deltoid involvement 1

Phase 2: Rehabilitation (Weeks 2-6)

Progressive Physical Therapy:

• Initiate when acute pain/swelling subsides: Begin gentle range of motion exercises to prevent stiffness 7, 4
• Eccentric strengthening exercises: Highly effective for reversing degenerative tendon changes if tendinopathy component present 1
• Progress systematically: Restore flexibility first, then strength, then endurance 7, 4
• Deep transverse friction massage: May help reduce pain in tendinopathy cases 1

Activity Modification:

• Gradual return to activities: Avoid premature return to full activity before adequate healing 9
• Protective measures during exercise: Consider taping or bracing during rehabilitation until full recovery 7

Phase 3: Refractory Cases (Beyond 6-8 Weeks)

If No Improvement After 6-8 Weeks of Conservative Treatment:

• Obtain MRI without contrast: To evaluate for occult tendon tears, chronic tendinopathy, or other pathology requiring different management 5, 2
• Consider specialist referral: Orthopedic or sports medicine consultation if imaging reveals significant structural pathology 1
• Surgery reserved for: Patients failing 3-6 months of consistent conservative therapy 1, 9

Expected Outcomes and Timeline

• Prognosis is generally excellent: Approximately 80% of patients with muscle strain and tendinopathy recover fully within 3-6 months with appropriate conservative management 1, 9, 4
• Complications are rare with proper treatment 4

Critical Pitfalls to Avoid

• Do NOT misdiagnose as acute inflammation ("tendinitis"): At one month post-injury, this likely represents chronic degenerative tendinosis, not acute inflammation, which changes treatment focus 1, 2
• Do NOT rely solely on NSAIDs: These provide short-term relief but do not address underlying degenerative process; must combine with physical therapy 1, 2
• Do NOT completely immobilize: This leads to muscle atrophy and deconditioning; relative rest with progressive mobilization is key 1, 9
• Do NOT delay imaging if red flags present: Severe pain out of proportion, progressive weakness, or systemic symptoms warrant urgent evaluation 5, 6
• Do NOT allow premature return to full activity: This leads to recurrence and prolonged recovery 9