What is the best course of treatment for a 24-year-old male with chronic shoulder pain, now exacerbated by a physical fitness test, with magnetic resonance imaging (MRI) findings of mild degenerative fraying of the anterior inferior labrum and an intact rotator cuff?

Management of Acute-on-Chronic Shoulder Pain with Labral Fraying

This 24-year-old male with burning pain and clicking after pushups most likely has progression of his anterior inferior labral pathology, possibly with associated rotator cuff tendinopathy from repetitive eccentric loading, and should begin a structured 8-12 week exercise-based rehabilitation program with NSAIDs while avoiding aggravating activities, particularly pushups and overhead movements. 1

Clinical Assessment Priority

The burning pain and clicking symptoms following pushup activity in a young male with known labral fraying strongly suggests:

• Labral pathology progression - The clicking is highly specific for labral tears, particularly in young athletes under 35 years, and physical examination has 90% sensitivity for detecting glenoid labral tears compared to MRI's 59% sensitivity 2
• Rotator cuff tendinopathy from eccentric overload - Pushups create repetitive eccentric stress on the supraspinatus and external rotators during the deceleration phase, which is the primary mechanism for rotator cuff injury in this age group 3
• The intact rotator cuff on prior MRI does not exclude tendinopathy - Tendinopathy can develop acutely from overload even with previously intact tendons 3

Key Physical Examination Findings to Obtain

• For labral pathology: Perform apprehension test, relocation test, crank test, and assess for clicking/catching during glenohumeral rotation - these have high diagnostic accuracy for labral tears 2
• For rotator cuff involvement: Empty can test, external rotation weakness testing, and pain with overhead activities 3
• For scapular dyskinesis: Observe scapular positioning during pushup motion, as poor scapular coordination may be both cause and effect of the underlying pathology 3

Initial Conservative Management (First 8-12 Weeks)

Start with structured exercise therapy combined with NSAIDs, as this approach shows large effect sizes in reducing pain and improving function in young athletes with shoulder pathology. 1, 4

Exercise Program Components

• Stretching exercises - Target posterior capsule and internal rotators 4
• Strengthening exercises - Focus on rotator cuff and scapular stabilizers, avoiding pushup movements initially 1, 4
• Dynamic stability exercises - Particularly important for athletes with labral pathology 4
• Range of motion exercises - To prevent stiffness while avoiding provocative positions 4

Activity Modification

• Immediately cease pushups and overhead loading activities that reproduce the burning pain and clicking 1
• Avoid cross-body adduction movements that stress the anterior labrum 3
• No throwing or overhead sports during the initial 8-week treatment period 4

Pharmacologic Management

• NSAIDs are recommended as part of initial conservative management for rotator cuff-related symptoms (moderate grade recommendation from AAOS) 1
• Avoid corticosteroid injections initially - While sometimes used, the evidence is conflicting and they may compromise tendon biology 1

Imaging Considerations

Plain radiographs should be obtained now if not already done to assess for:

• Fracture (particularly important given acute exacerbation from trauma) 5, 1
• Shoulder alignment 5, 1
• Bony Bankart lesions or Hill-Sachs deformities 5

Advanced imaging decision algorithm:

• If symptoms significantly improve with conservative management by 8-12 weeks: Continue conservative care, no advanced imaging needed 1
• If inadequate response at 8-12 weeks: Obtain MRI without contrast (preferred) or ultrasound to evaluate for progression of labral tear or development of rotator cuff tear 5, 1
• MR arthrography is NOT indicated acutely because the acute pathology will produce joint effusion that serves the same purpose as contrast for assessing intra-articular structures 5

Reassessment Timeline and Surgical Consideration

• Reassess at 8-12 weeks: Most patients show significant improvements in pain scores after 8 weeks of exercise therapy 1
• Surgery should only be considered if:
  • Conservative management fails after adequate 3-6 month trial 1
  • Advanced imaging reveals significant full-thickness rotator cuff tear requiring repair 1
  • Recurrent instability episodes occur despite rehabilitation 5

Critical Pitfalls to Avoid

• Do not assume the prior MRI findings are still current - The acute exacerbation may represent progression of the labral pathology or new rotator cuff involvement 3
• Do not allow return to pushups or overhead activities until pain-free and strength is restored, as premature return will perpetuate the injury cycle 4
• Do not rush to advanced imaging - Physical examination is more accurate than MRI for labral tears (90% vs 59% sensitivity), and imaging should be reserved for failed conservative management 2
• Do not overlook scapular dyskinesis - This contributes significantly to both rotator cuff and labral injuries and must be addressed in rehabilitation 3