What are the treatment options for anterior shoulder pain?

Treatment Options for Anterior Shoulder Pain

Begin with plain radiographs (AP views in internal and external rotation plus axillary or scapular-Y view) as the initial diagnostic step, followed by a structured conservative treatment program of physical therapy focusing on rotator cuff and scapular stabilizer strengthening for 6-12 weeks before considering advanced imaging or surgical referral. 1

Initial Diagnostic Approach

Radiography is mandatory as the first imaging study because it identifies fractures, dislocations, and malalignment—the primary concerns requiring immediate management decisions 1. The standard three-view series must include:

• AP views in internal and external rotation 1
• Axillary or scapular-Y view (critical because glenohumeral and acromioclavicular dislocations are frequently misclassified on AP views alone) 1
• Perform radiographs upright rather than supine, as malalignment can be underrepresented in supine positioning 1

Conservative Treatment Protocol (First-Line for 6-12 Weeks)

Phase 1: Initial Treatment (0-6 weeks)

Start with gentle stretching and mobilization techniques emphasizing increased external rotation and abduction 2. The treatment program should include:

• NSAIDs (ibuprofen or acetaminophen) for pain control 2
• Gradual progression of active range of motion exercises while restoring shoulder girdle alignment 2
• Strengthening of rotator cuff, periscapular muscles, and core musculature 2, 3
• Address anterior shoulder girdle flexibility while strengthening posterior shoulder girdle and neck 2

Consider subacromial corticosteroid injection if pain significantly limits participation in physical therapy, though benefits are temporary 2. Ultrasound-guided injections provide more accurate placement 2.

Phase 2: Intermediate Treatment (6-12 weeks)

Progress to intensive strengthening exercises targeting rotator cuff and scapular stabilizers 2. Critical components include:

• Address scapular dyskinesis through specific corrective exercises 2
• Emphasize posterior shoulder musculature strengthening to counterbalance overdeveloped anterior muscles 2
• Continue flexibility work for the shoulder capsule 2
• Assess and treat the entire kinetic chain, including core and spine mechanics 2

When to Obtain Advanced Imaging

Order MRI without contrast if:

• Conservative management fails after 6-12 weeks of appropriate physical therapy 3
• Clinical features suggest full-thickness rotator cuff tear: significant weakness on resisted external rotation, positive impingement signs, or age >60 years with combination of these findings 3
• Surgical planning is being considered 3

MRI is the preferred advanced imaging modality because it effectively demonstrates rotator cuff tears, osseous contusions, acromioclavicular sprains, and bony abnormalities following glenohumeral dislocation 1. In the acute posttraumatic setting, noncontrast MRI is preferred over MR arthrography 1.

CT without contrast is indicated when:

• Radiographs show complex comminuted fractures requiring detailed characterization (CT affects clinical management in up to 41% of proximal humeral fractures) 1
• Subtle nondisplaced fractures are suspected, particularly scapular fractures frequently missed on radiographs 1

Surgical Referral Criteria

Refer urgently for orthopedic evaluation if:

• Unstable or significantly displaced fractures are present 1, 3
• Joint instability or dislocation requiring acute surgical treatment 1, 3
• Full-thickness rotator cuff tear with tendon retraction, muscle atrophy, or fatty infiltration on MRI 3
• Massive traumatic rotator cuff tears (may require expedited timeline for optimal functional outcomes) 1
• Instability symptoms persist or recur after completing physical therapy 2

Critical Pitfalls to Avoid

Distinguish between primary impingement (structural) and secondary impingement (functional/dynamic), as this determines appropriate treatment planning 2.

Do not overlook scapular dyskinesis assessment and treatment—this is essential for successful resolution 2.

Screen for concurrent conditions like adhesive capsulitis or rotator cuff tendinopathy that may complicate treatment 2.

In throwing athletes, assess for spinal accessory nerve injury which can cause scapular winging 2.

Avoid being overly restrictive with exercise prescription while maintaining appropriate precautions 2.

Early intervention positively influences treatment response—delays in treatment are associated with poorer outcomes 4.