What is the best course of treatment for a patient with right shoulder pain exacerbated by rotator cuff exercises and mild degenerative changes at the acromioclavicular joint?

Treatment Recommendation for Right Shoulder Pain with AC Joint Degeneration

Begin with a structured 6-12 week trial of conservative management combining exercise therapy and NSAIDs before considering any advanced imaging or interventional procedures. 1

Initial Conservative Management (First-Line Treatment)

Exercise Therapy - Primary Treatment Modality

• Implement a progressive exercise program as the cornerstone of treatment, focusing on rotator cuff strengthening and scapular stabilization 1
• Exercise therapy demonstrates significant improvements in pain scores (VAS) and Constant-Murley scores after 8-12 weeks in patients with rotator cuff-related symptoms 1
• The exercise program should address the eccentric loading dysfunction evident from pain during rotator cuff exercises, as this suggests chronic undersurface rotator cuff wear 2
• Include scapular dyskinesis correction, as poor scapular coordination during exercises may be both cause and effect of the underlying pathology 2

Pharmacologic Management

• Prescribe NSAIDs for pain relief and inflammation control as part of multimodal conservative care 1
• NSAIDs should be used for the shortest period necessary while exercise therapy takes effect 1

Activity Modification

• Temporarily modify or eliminate rotator cuff exercises that exacerbate symptoms, then progressively reintroduce them as tolerance improves 1
• Avoid overhead activities and movements that reproduce the pain during the initial treatment phase 2

When to Consider Additional Interventions

Subacromial Corticosteroid Injection - Conditional Use

• Consider subacromial corticosteroid injection only if conservative management shows inadequate response after 4-6 weeks, though evidence for this intervention is conflicting 1
• Five level II studies show mixed results for corticosteroid injections, with variable outcomes for pain and function between 2-6 weeks 1
• If used, corticosteroid injection should be combined with continued exercise therapy, not as standalone treatment 1

Advanced Imaging - Reserved for Specific Indications

• Do not obtain MRI or ultrasound unless there is failure to respond to 6-12 weeks of conservative care 1
• The current radiographs showing mild AC joint degeneration and no rotator cuff calcifications are sufficient for initial management 1
• Advanced imaging is only indicated if: (1) symptoms progress unexpectedly, (2) conservative care fails, or (3) findings would change management decisions 1

Surgical Consideration Threshold

• Refer for surgical evaluation only after documented failure of 3 months of structured conservative management 1
• For rotator cuff-related shoulder pain without full-thickness tears, arthroscopic procedures provide little to no clinically important benefits compared to non-operative treatment 1
• Surgery should be considered only if there is symptomatic full-thickness rotator cuff tear confirmed on imaging after failed conservative care 1

Treatment Timeline and Monitoring

Weeks 0-6

• Initiate exercise therapy with physical therapy supervision 1
• Start NSAIDs for symptom control 1
• Modify aggravating activities 2
• Reassess at 4-6 weeks for response 1

Weeks 6-12

• Continue exercise progression if showing improvement 1
• Consider subacromial injection if inadequate response 1
• Order MRI/ultrasound only if no improvement and considering surgical referral 1

Beyond 12 Weeks

• Refer to orthopedics if persistent symptoms despite optimal conservative care 1
• Document specific functional limitations and failed interventions for surgical consultation 1

Critical Pitfalls to Avoid

• Do not rush to advanced imaging - the mild AC joint degeneration seen on radiographs does not require immediate MRI, as imaging findings often do not correlate with symptoms 1
• Do not use manual therapy or injections as standalone treatments - these must be combined with exercise therapy to be effective 1
• Do not assume the AC joint degeneration is the primary pain generator - the pain pattern exacerbated by rotator cuff exercises suggests rotator cuff pathology as the primary issue, with AC joint changes being an incidental age-related finding 2, 3
• Avoid premature surgical referral - patients over 35-40 years with rotator cuff-related symptoms typically respond well to conservative management 1, 2