What is the best course of treatment for a patient with shoulder pain and limited range of motion after repetitive overhead movements, with tenderness over the greater tuberosity of the proximal humerus and pain on abduction and flexion?

Treatment of Subacromial Impingement Syndrome

This patient has classic subacromial impingement syndrome from repetitive overhead activity, and should be treated with a structured physical therapy program emphasizing gentle stretching (particularly external rotation and abduction), gradual strengthening of rotator cuff and scapular stabilizers, combined with NSAIDs (ibuprofen 400-800mg every 6-8 hours) for pain relief. 1, 2, 3

Clinical Diagnosis

The presentation is diagnostic for subacromial impingement:

• Painful arc between 60-120° of abduction/flexion is pathognomonic for subacromial pathology 4
• Tenderness over the greater tuberosity indicates rotator cuff or bursal inflammation 4
• Normal rotator cuff strength rules out full-thickness tear 4
• Insidious onset after repetitive overhead work confirms mechanical etiology 4

Imaging is not necessary at this stage since symptoms have been present for only 10 days and there was no trauma; plain radiographs would only be indicated if symptoms persist beyond 6-8 weeks of conservative treatment 4

First-Line Treatment Protocol

Physical Therapy (Primary Treatment)

Gentle stretching and mobilization must focus specifically on external rotation and abduction to address the impingement mechanism and prevent frozen shoulder 1, 2. This is the cornerstone of treatment with high-level evidence supporting its efficacy.

• Active range of motion should be increased gradually while simultaneously restoring proper shoulder alignment and strengthening weak muscles in the shoulder girdle 1, 2
• Avoid overhead pulley exercises as they encourage uncontrolled abduction and may worsen pain 1, 2
• Apply ice before exercises for symptomatic relief and pain reduction 2
• Soft tissue massage can reduce pain and improve tissue elasticity 2

Pharmacologic Management

Ibuprofen is superior to acetaminophen for rotator cuff-related pain based on direct comparative evidence showing improvement in both pain severity and functional activity with ibuprofen, while acetaminophen only improved quality of life measures without functional benefit 3

• Ibuprofen 400-800mg every 6-8 hours is the recommended dose; notably, all three doses (400mg, 600mg, 800mg) provide equivalent analgesia, so starting with 400mg is reasonable to minimize side effects 3, 5
• Duration should be limited to the acute inflammatory phase (typically 2-4 weeks) 6
• Use with caution in patients with history of gastrointestinal bleeding, cardiovascular disease, or chronic renal disease 6

Progression of Treatment

Intermediate Phase (Weeks 2-6)

Once acute pain improves:

• Progress to intensive strengthening exercises targeting rotator cuff and scapular stabilizers 2
• Emphasize posterior shoulder musculature strengthening to counterbalance overdeveloped anterior muscles from the overhead work 2
• Address scapular dyskinesis through specific exercises, as this is essential for successful outcomes 2

Advanced Phase (Weeks 6-12)

• Implement graduated return to overhead activities with emphasis on proper mechanics 2
• Ensure complete resolution of symptoms before returning to full wallpapering or similar overhead work 2

Second-Line Interventions (If Conservative Treatment Fails)

If symptoms persist after 6-8 weeks of appropriate physical therapy and NSAIDs:

• Subacromial corticosteroid injection is indicated when pain is related to rotator cuff or bursa inflammation 1, 7
• Consider ultrasound evaluation at this point to assess for structural pathology 7

Critical Pitfall to Avoid

The sleep disturbance mentioned is significant and indicates moderate-to-severe pain that may interfere with rehabilitation participation. This patient needs adequate pain control to engage effectively in physical therapy 7. Consider:

• Taking ibuprofen before bedtime to improve sleep quality
• Proper positioning during sleep (avoid sleeping on affected shoulder) 1

Do not delay physical therapy while waiting for pain to resolve spontaneously - early mobilization prevents the development of adhesive capsulitis (frozen shoulder), which is a common complication of untreated shoulder pain 1, 2