What is the best course of treatment for a patient who can initiate shoulder abduction but is limited by pain?

Management of Shoulder Pain with Preserved Abduction Initiation

Begin with standard shoulder radiographs (AP views in internal and external rotation plus axillary or scapula-Y view) to exclude fracture or dislocation, then immediately initiate conservative management with gentle stretching focusing on external rotation and abduction, combined with NSAIDs and ice application. 1, 2

Immediate Diagnostic Workup

Obtain three-view radiographic series first to rule out fracture, dislocation, or significant bony pathology before proceeding with any treatment. 3, 2 The ability to initiate abduction suggests the rotator cuff is at least partially intact, but imaging remains mandatory to exclude structural damage. 3

• The standard trauma series must include: anteroposterior views in internal and external rotation, plus either axillary or scapula-Y view 3, 2
• Axillary or scapula-Y views are critical because dislocations can be missed on AP views alone 3, 2
• Perform radiographs upright, as malalignment can be underrepresented on supine films 3

First-Line Conservative Treatment Protocol

Most soft-tissue injuries including labral tears and rotator cuff tears can undergo conservative management before considering surgery. 3 The painful arc pattern you describe is pathognomonic for subacromial pathology (rotator cuff or bursal inflammation), and preserved strength rules out full-thickness rotator cuff tear. 1

Phase 1: Pain Control and Protection (Days 1-14)

• Apply ice before exercises for symptomatic relief and pain reduction 1, 2
• Initiate NSAIDs immediately: Naproxen 500 mg twice daily (or 250 mg every 6-8 hours for acute pain) 4, 5
• Complete rest from aggravating activities until acute symptoms resolve 2
• Soft tissue massage to reduce pain and improve tissue elasticity 1, 2

Phase 2: Gentle Mobilization (Weeks 2-4)

Begin gentle stretching and mobilization focusing specifically on external rotation and abduction to address the impingement mechanism and prevent frozen shoulder. 3, 1, 2 This intervention has high-level evidence supporting its efficacy. 1

• Use active, active-assisted, or passive range of motion exercises performed in safe positions 2
• Gradually increase active range of motion while restoring proper shoulder alignment 1, 2
• Critical pitfall to avoid: Do NOT use overhead pulleys, as they encourage uncontrolled abduction and can worsen shoulder pathology 3, 1, 2

Phase 3: Progressive Strengthening (Weeks 4-12)

Progress to intensive strengthening exercises targeting rotator cuff and scapular stabilizers once acute pain improves, emphasizing posterior shoulder musculature strengthening. 1

• Strengthen rotator cuff and scapular stabilizer muscles 2
• Eccentric training for shoulder abductors at 60°/s improves pain, function, and isokinetic performance 6
• Re-establish proper mechanics of the shoulder and spine 2
• Progress to dynamic stabilization exercises 2

Adjunctive Interventions

Consider subacromial corticosteroid injection (triamcinolone) if pain is related to rotator cuff or bursal inflammation and conservative measures provide insufficient relief. 3, 1, 2 Intra-articular injections have significant effects on pain reduction. 3

• Functional electrical stimulation can be considered for persistent pain 3, 2
• Shoulder strapping may prolong time to pain onset but shows mixed evidence 3

When to Escalate Care

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. 2 However, surgery is not convincingly better than conservative interventions for subacromial impingement. 7

• Unstable or significantly displaced fractures require acute surgical management 3, 2
• Joint instability with recurrent dislocation requires urgent orthopedic consultation 3, 2

Return to Activity Criteria

Return to normal activities only after achieving pain-free motion and adequate strength. 2 Implementing a graduated return to overhead activities with emphasis on proper mechanics is essential. 1

• Ensure complete resolution of symptoms before returning to full activities 1
• Duration of conservative treatment typically ranges from 1-3 months depending on injury severity 2
• Common pitfall: Returning to activity too soon before adequate healing can lead to chronic pain and dysfunction 2

Sleep and Quality of Life Considerations

Take NSAIDs before bedtime to improve sleep quality, and avoid sleeping on the affected shoulder with proper positioning during sleep. 1 Early mobilization prevents the development of adhesive capsulitis (frozen shoulder). 1