What is the best management approach for a patient with shoulder pain and restricted range of motion?

Management of Shoulder Pain with Limited 90° Upward Motion

Begin immediately with gentle stretching and mobilization exercises focusing on external rotation and abduction, combined with ice application before exercises and NSAIDs for pain control, while avoiding overhead pulley exercises that can worsen the condition. 1

Initial Clinical Assessment

Your first priority is determining whether this represents subacromial impingement versus other pathology:

• Look for a painful arc between 60-120° of abduction/flexion, which is pathognomonic for subacromial pathology (rotator cuff or bursal inflammation) 1
• Test rotator cuff strength: Normal strength rules out full-thickness tear 1
• Assess for cervical spine involvement: Restricted cervical motion or pain may contribute to shoulder symptoms and requires concurrent treatment 2
• Evaluate muscle tone, soft tissue changes, joint alignment of the shoulder girdle, and pain levels to identify specific impairments 3

First-Line Treatment Protocol (Weeks 1-3)

Range of Motion Restoration

• Start with gentle passive and active-assisted range of motion exercises, placing the arm in safe positions within the patient's visual field 3
• Focus specifically on external rotation and abduction movements to address the impingement mechanism 1, 3
• Progress active range of motion gradually while simultaneously restoring proper shoulder alignment 1, 3
• Critical pitfall: Never use overhead pulley exercises—these encourage uncontrolled abduction and will worsen pain 4

Pain Management Strategy

• Apply ice before each exercise session for symptomatic relief and pain reduction 1
• Prescribe ibuprofen (superior to acetaminophen for rotator cuff-related pain), taken before bedtime to improve sleep quality 1, 3
• Soft tissue massage can reduce pain and improve tissue elasticity 1

Muscle Strengthening

• Begin strengthening weak muscles in the shoulder girdle as soon as acute pain allows 1, 3
• Avoid exercises that reproduce the painful arc initially 1

Progression Phase (Weeks 4-8)

Once acute pain improves:

• Advance to intensive strengthening exercises targeting rotator cuff and scapular stabilizers 1
• Emphasize posterior shoulder musculature strengthening and address any scapular dyskinesis 1
• Implement graduated return to overhead activities with proper mechanics 1

Adjunctive Interventions to Consider

For Persistent Pain Despite Physical Therapy

• Subacromial corticosteroid injection when pain is clearly related to rotator cuff or bursa inflammation 1
• Ultrasound evaluation to assess for structural pathology if not improving 1

For Cervical Spine Involvement

• Cervicothoracic spine manipulation and mobilization if shoulder pain is associated with cervical pain or restricted cervical movement 5
• Joint mobilization directed at impaired cervical spine segments may significantly improve shoulder outcomes 2

Additional Modalities with Evidence

• Low-level laser therapy can be considered for shoulder pain of any duration 5
• Multimodal care combining heat/cold, joint mobilization, and range of motion exercise is effective 5

Critical Pitfalls to Avoid

• Never allow the patient to sleep on the affected shoulder—proper positioning during sleep is essential 1
• Early mobilization is mandatory to prevent development of adhesive capsulitis (frozen shoulder) 1
• Do not use static positioning or strapping of the upper extremity—evidence for preventing loss of range of motion or pain is not well established 6
• Avoid ultrasound therapy, taping, and interferential current therapy—these are not recommended for shoulder pain 5

When to Reassess

• Evaluate at each visit for worsening symptoms, new physical/psychological symptoms, or satisfactory recovery 5
• Ensure complete resolution of symptoms before returning to full overhead activities 1
• If no improvement after 3-4 weeks of conservative management, consider imaging and specialist referral 1