What is the best course of action for a patient in their 50s with right shoulder pain and limited range of motion (ROM) after a fall while snowboarding?

Immediate Imaging and Orthopedic Evaluation for Acute Traumatic Shoulder Injury

A patient in their 50s with acute traumatic shoulder pain and limited ROM after a snowboarding fall requires immediate plain radiographs to rule out fracture or dislocation, followed by structured conservative management if imaging is negative, with early mobilization being critical to prevent adhesive capsulitis. 1, 2

Initial Diagnostic Approach

Essential History Documentation

• Document the exact fall mechanism: height of fall, landing position (direct shoulder impact vs. outstretched hand), and whether the arm was in an abducted/externally rotated position at impact 1
• Assess for instability symptoms: any sensation of the shoulder "giving way," popping, or visible deformity immediately after the fall suggests dislocation 1
• Pain location matters: anterior shoulder pain suggests rotator cuff or biceps injury; superior pain indicates acromioclavicular joint injury; inability to initiate abduction suggests complete rotator cuff tear 1

Critical Physical Examination Findings

• Test rotator cuff strength immediately: normal strength rules out full-thickness tear, while profound weakness with inability to maintain arm elevation suggests complete tear requiring surgical consultation 2
• Assess for painful arc between 60-120° of abduction: this finding is pathognomonic for subacromial pathology (rotator cuff or bursal inflammation) 2
• Check passive ROM: if passive ROM is preserved but active ROM is limited, this suggests rotator cuff pathology rather than adhesive capsulitis 3

Mandatory Imaging

• Plain radiographs are essential first-line imaging in all traumatic shoulder injuries in patients over 50 years, as osteoporotic fractures can occur with minimal trauma that patients may not even recall 1
• Consider ultrasound evaluation within the first week if radiographs are negative but clinical suspicion for rotator cuff tear remains high based on weakness 2

First-Line Conservative Management (Weeks 1-3)

Immediate Pain Control

• Prescribe ibuprofen taken before bedtime: this is superior to acetaminophen for rotator cuff-related pain and improves sleep quality 2
• Apply ice before each exercise session for symptomatic relief and pain reduction 2

Critical Early Mobilization Protocol

• Begin gentle passive and active-assisted ROM exercises immediately (within 48-72 hours if fracture ruled out), placing the arm in safe positions within the patient's visual field 2
• Focus specifically on external rotation and abduction movements to address the impingement mechanism and prevent frozen shoulder 2, 4
• Early mobilization is mandatory: delaying mobilization significantly increases risk of adhesive capsulitis (frozen shoulder), which is particularly common in patients over 50 years 2

Positioning Instructions

• Never allow sleeping on the affected shoulder: proper positioning during sleep is crucial for recovery 2
• Avoid static positioning or prolonged sling use: evidence does not support strapping or immobilization for preventing pain or loss of ROM, and prolonged immobilization increases adhesive capsulitis risk 4, 2

Progression Phase (Weeks 4-8)

Structured Rehabilitation

• Progress active ROM gradually while simultaneously restoring proper shoulder alignment and strengthening weak muscles in the shoulder girdle 4, 2
• Advance to intensive strengthening exercises targeting rotator cuff and scapular stabilizers once pain-free ROM approaches normal 2
• Emphasize posterior shoulder musculature strengthening and address any scapular dyskinesis (abnormal shoulder blade movement patterns) 1

Adjunctive Interventions

Corticosteroid Injection Timing

• Subacromial corticosteroid injection is indicated when pain is clearly related to rotator cuff or bursa inflammation and conservative measures have not provided adequate relief after 2-3 weeks 4, 2
• Subacromial injections are preferred over glenohumeral injections for rotator cuff-related pain in this clinical scenario 4

Red Flags Requiring Urgent Orthopedic Referral

• Profound weakness with inability to initiate shoulder abduction suggests complete rotator cuff tear requiring surgical evaluation 2
• No improvement after 3-4 weeks of structured conservative management warrants advanced imaging (MRI or ultrasound) and specialist referral 2
• Development of progressive stiffness with loss of passive ROM suggests evolving adhesive capsulitis requiring aggressive physical therapy and possible intra-articular corticosteroid injection 4

Critical Pitfalls to Avoid

• Do not assume absence of recalled trauma means absence of fracture: osteoporotic fractures in patients over 50 can occur with minimal or unrecognized trauma 1
• Avoid overhead pulley exercises: these encourage uncontrolled abduction and can worsen rotator cuff pathology 4
• Never delay mobilization beyond 1 week (if fracture excluded): this is the single most important factor in preventing adhesive capsulitis 2