What are the recommended treatments and management for a fall onto the right shoulder with limited range of motion (ROM) and tenderness upon palpation of the deltoid muscle?

Acute Traumatic Shoulder Injury Management

This patient requires immediate radiographic evaluation with a three-view trauma series (AP in internal/external rotation plus axillary or scapula-Y view) to rule out fracture or dislocation, followed by conservative management with relative rest, ice, NSAIDs, and early gentle range-of-motion exercises focusing on external rotation and abduction. 1, 2

Immediate Diagnostic Priorities

Critical first step: Obtain plain radiographs before any other intervention. 2

• Mandatory three-view trauma series: anteroposterior views in both internal and external rotation, plus either axillary or scapula-Y view 1, 2
• The axillary or scapula-Y view is non-negotiable—glenohumeral and acromioclavicular dislocations are frequently missed on AP views alone 2, 3
• Posterior dislocations are missed in over 60% of cases initially and require scapular plane imaging 3

Physical examination findings to document:

• Degree of deltoid tenderness and any visible atrophy (suggests chronicity) 4
• Specific ROM limitations in all planes, particularly external rotation and abduction 4, 1
• Presence of posterior fullness or anterior flatness suggesting dislocation 3
• Palpate for well-localized tenderness over the deltoid insertion and rotator cuff 4

First-Line Treatment Protocol

Begin immediately after fracture/dislocation is ruled out:

Pain Control

• NSAIDs (ibuprofen) are the preferred analgesic for acute shoulder pain related to soft tissue injury 1, 2
• Take ibuprofen before bedtime to improve sleep quality 5
• Apply ice before exercises for symptomatic relief 5
• Avoid sleeping on the affected shoulder 5

Early Mobilization Strategy

• Start gentle stretching and mobilization within days, NOT weeks—early mobilization prevents adhesive capsulitis (frozen shoulder) 5, 2
• Focus specifically on external rotation and abduction movements 1, 5, 2
• Use active, active-assisted, or passive ROM exercises performed within the patient's visual field 2
• Critical pitfall to avoid: Do NOT use overhead pulley exercises—they encourage uncontrolled abduction and worsen pain 1, 5, 2

Relative Rest

• Complete rest from aggravating activities until acute symptoms resolve 2
• Reduce repetitive loading of potentially damaged tendons 4

Supportive Measures

• Consider shoulder strapping or sling for support, especially if subluxation is present 1, 2
• Soft tissue massage can reduce pain and improve tissue elasticity 5, 2

Progressive Rehabilitation (After Acute Phase)

Once acute pain improves (typically 1-2 weeks):

• Gradually increase active ROM while restoring proper shoulder alignment 1, 5, 2
• Progress to strengthening exercises targeting rotator cuff and scapular stabilizers, emphasizing posterior shoulder musculature 5
• Address any scapular dyskinesis 5
• Incorporate core and lumbopelvic strengthening as part of the kinetic chain 2

Second-Line Interventions (If Conservative Management Insufficient)

Consider at 2-4 weeks if pain persists despite appropriate conservative care:

• Subacromial corticosteroid injection if pain is related to rotator cuff or bursa inflammation 1, 5, 2
• Ultrasound evaluation to assess for structural pathology (rotator cuff tears, bursal inflammation) 5, 2
• Neuromuscular electrical stimulation (NMES) may be considered for persistent pain 1, 2

When to Escalate Care

Obtain MRI if:

• Symptoms persist beyond 3 months despite appropriate conservative management 2
• Clinical suspicion for massive rotator cuff tear (may require expedited surgical repair) 2, 6

Red flags requiring urgent orthopedic consultation:

• Unstable or significantly displaced fractures 2
• Joint instability with recurrent dislocation 2
• Complete inability to initiate abduction (suggests massive rotator cuff tear or axillary nerve injury) 6, 7

Expected Recovery Timeline

• Most patients with overuse tendinopathies recover fully within 3-6 months (approximately 80%) 4
• Duration of conservative treatment typically ranges from 1-3 months depending on injury severity 2
• Return to normal activities only after achieving pain-free motion and adequate strength 2

Common Pitfall

The deltoid requires significant compensatory function when rotator cuff is injured—returning to activity too soon before adequate healing and strengthening can lead to chronic pain and dysfunction. 2, 7