What is the best course of treatment for a patient with posterior shoulder pain when rotating the arm inward and extending it superiorly?

Posterior Shoulder Pain with Internal Rotation and Superior Extension

Begin with conservative management including complete rest from aggravating activities, posterior capsular stretching exercises, NSAIDs, and rotator cuff strengthening, as this presentation most likely represents posterior capsular contracture or internal impingement syndrome. 1, 2, 3

Clinical Diagnosis

This specific pain pattern—posterior shoulder pain with internal rotation and superior extension (overhead motion)—strongly suggests one of two related conditions:

Primary Diagnostic Considerations

Posterior capsular contracture is the most likely diagnosis when posterior shoulder pain occurs with internal rotation and forward flexion, as the contracted posterior capsule restricts normal glenohumeral motion and causes increased anterosuperior translation of the humeral head. 4

• The restricted internal rotation combined with reproduction of posterior pain is pathognomonic for this condition. 4
• This can mimic impingement syndrome but is distinguished by the presence of restricted range of motion, particularly limited internal rotation. 4

Internal (posterosuperior) impingement syndrome should be considered, especially in overhead athletes, where the rotator cuff and joint capsule impinge against the posterosuperior glenoid during the combined motion of abduction with internal rotation. 3

• This differs from classic external impingement, which involves compression under the coracoacromial arch. 3
• The etiology may include anterior micro-instability, posterior capsular contracture, or scapular dyskinesis. 3

Initial Management Protocol

Phase 1: Pain Control and Rest (Weeks 1-2)

Immediately cease all aggravating activities until acute symptoms resolve. 2

Initiate pharmacologic pain management:

• NSAIDs (ibuprofen or naproxen) as first-line therapy if no contraindications exist. 2, 5
• Acetaminophen as an alternative for patients with NSAID contraindications. 2

Apply ice therapy to reduce pain and inflammation in the acute phase. 2, 5

Phase 2: Restore Range of Motion (Weeks 2-6)

Aggressive posterior capsular stretching is the cornerstone of treatment for this specific pain pattern. 4

• The primary goal is restoring normal internal rotation such that the loss of internal rotation does not exceed any compensatory increase in external rotation. 4
• Perform stretching exercises multiple times daily, focusing specifically on increasing internal rotation and forward flexion. 2

Use active-assisted or passive range of motion exercises performed within the patient's visual field in safe positions. 2

Critical pitfall to avoid: Do NOT use overhead pulleys, as uncontrolled abduction can worsen the underlying pathology. 2

Phase 3: Strengthening (Weeks 6-12)

Begin rotator cuff strengthening exercises once pain-free motion is achieved. 1, 2, 5

Address scapular dyskinesis through scapular stabilizer strengthening, as poor scapular mechanics contribute significantly to this condition. 1, 3

Progress to dynamic stabilization exercises incorporating core and lumbopelvic strengthening as part of the kinetic chain. 2

Adjunctive Interventions

Consider subacromial corticosteroid injection if conservative measures fail after 4-6 weeks and pain is thought related to bursal inflammation. 2, 5

Soft tissue massage and heat therapy may provide additional symptomatic relief. 2

When to Escalate Care

If symptoms persist beyond 3 months despite appropriate conservative management, obtain MRI to evaluate for rotator cuff tears, labral pathology (including SLAP lesions in throwing athletes), or other soft tissue injuries requiring surgical intervention. 2, 3

Arthroscopic posterior capsule release can be considered for refractory posterior capsular contracture after failed conservative management, with good outcomes for improved motion and pain relief. 4

For internal impingement in athletes, surgical treatment should address any associated subtle instability, as outcomes improve when this component is corrected. 3

Return to Activity

Return to normal activities only after achieving pain-free motion and adequate strength, typically requiring 1-3 months depending on severity. 2

Common pitfall: Premature return to activity before adequate healing and strengthening leads to chronic pain and dysfunction. 2

Red Flags Requiring Imaging

Obtain initial radiographs (AP in internal/external rotation plus axillary or scapula-Y view) if there is any history of trauma, even minor, to rule out fracture or dislocation. 6, 2

• This is mandatory first-line imaging for any traumatic presentation. 2
• Elderly patients can sustain osteoporotic fractures with minimal trauma. 1