What treatment is recommended for a shoulder injury from a FOOSH with weakness and pain, especially with overhead lifting?

Management of Acute Shoulder Injury from FOOSH with Weakness and Overhead Pain

Begin with standard shoulder radiographs (AP views in internal and external rotation plus axillary or scapula-Y view) to rule out fracture or dislocation, followed by conservative management with complete rest from overhead activities, structured rehabilitation targeting rotator cuff and scapular stabilizers, and progression only when pain-free. 1

Initial Diagnostic Approach

Radiography is mandatory as the first imaging study for any traumatic shoulder injury to identify fractures and shoulder malalignment, which are the primary concerns requiring immediate intervention. 1 The standard trauma series must include:

• AP views in both internal and external rotation 1
• Axillary or scapula-Y view (critical because glenohumeral and acromioclavicular dislocations can be missed on AP views alone) 1
• Upright positioning when possible, as supine radiography can underrepresent shoulder malalignment 1

Common pitfall: Obtaining only AP views will miss dislocations and subtle malalignment that are only visible on axillary or Y views. 1

Most Likely Diagnosis Based on Presentation

Given the mechanism (FOOSH 2 days ago) with weakness and pain specifically with overhead lifting, the differential includes:

• Rotator cuff injury (most likely given weakness with overhead motion and pain with ROM) 1
• Anterior shoulder dislocation with reduction (weakness from posterior rotator cuff injury, particularly infraspinatus and teres minor) 2
• Acromioclavicular separation (if tenderness localizes to AC joint) 1

Pain with overhead lifting specifically indicates rotator cuff pathology, as this motion requires supraspinatus function and intact rotator cuff mechanics. 1

Conservative Management Protocol (First-Line Treatment)

Most soft-tissue shoulder injuries, including rotator cuff tears and labral tears, should undergo a period of conservative management before considering surgery. 1 Only unstable or significantly displaced fractures and joint instability require acute surgical intervention. 1

Phase 1: Complete Rest (Until Asymptomatic)

• Mandatory complete rest from all overhead activities and lifting until the patient is asymptomatic 1, 3
• Analgesics (acetaminophen or ibuprofen) for pain relief if no contraindications 1
• Gentle stretching and mobilization techniques to prevent loss of range of motion, particularly focusing on external rotation and abduction 1

Critical caveat: Do not progress to strengthening exercises while still symptomatic, as this perpetuates the injury cycle. 1

Phase 2: Rehabilitation Program (After Pain Resolution)

The structured rehabilitation must target specific muscle groups in sequence:

1. Rotator cuff strengthening (particularly external rotators, supraspinatus, infraspinatus, and teres minor) 1, 4, 2
2. Scapular stabilizer strengthening (periscapular muscles to restore proper scapular mechanics) 1, 4
3. Re-establishing proper shoulder and spine mechanics 1
4. Restoring full active range of motion gradually in conjunction with strengthening 1

The biomechanical rationale: Weakened posterior shoulder musculature combined with relatively stronger anterior musculature creates the environment for ongoing injury and prevents the humeral head from staying centered in the glenoid during arm motion. 1, 2 Rehabilitation must restore this transverse force couple balance. 2

Phase 3: Criteria-Based Progression

Progress to loaded activities only when ALL criteria are met: 3

• Pain-free performance of current exercises
• Full active range of motion achieved
• No increase in resting pain or night pain
• Proper scapular mechanics demonstrated during movement 3

Duration: Expect 1-3 months of rehabilitation depending on injury severity, with tendon/ligament injuries requiring significantly longer than bone injuries. 1, 4

When to Consider Advanced Imaging or Surgical Consultation

If symptoms persist or progress despite 3-6 months of appropriate rehabilitation, obtain MRI and surgical consultation. 3 Earlier imaging (MRI or ultrasound) may be warranted if:

• Significant weakness persists beyond 2-4 weeks despite rest 1
• Complete inability to perform overhead activities after initial rest period 1
• Suspicion of complete rotator cuff tear based on profound weakness 1

Special Considerations for Specific Injuries

If Anterior Dislocation Suspected (Based on Mechanism)

The infraspinatus and teres minor demonstrate significant weakness and atrophy following anterior shoulder dislocation, creating muscular imbalance where anterior structures overpower weakened posterior external rotators. 2 Rehabilitation must aggressively target external rotator strengthening. 2

If Rotator Cuff Tear Confirmed

Strong evidence shows physical therapy improves patient-reported outcomes in symptomatic full-thickness rotator cuff tears, though surgical repair shows superior outcomes when tears are small to medium-sized and successfully healed. 3 Conservative management remains first-line unless the tear is large or involves significant functional impairment. 3

Red Flags Requiring Immediate Intervention

• Unstable or significantly displaced fracture on radiographs (requires acute surgical management) 1
• Joint instability or dislocation (requires acute reduction and surgical evaluation) 1
• Progressive neurological symptoms (may indicate nerve injury requiring urgent evaluation) 2