What is the initial management for a patient with shoulder pain and limited mobility, unable to put their arm behind their back, with potential for adhesive capsulitis or rotator cuff injury?

Evaluation and Initial Management of Shoulder Pain with Inability to Place Arm Behind Back

Start with plain radiographs (anteroposterior views in internal and external rotation plus axillary or scapular Y view) to rule out fracture, dislocation, and glenohumeral osteoarthritis, then initiate conservative management with structured exercise therapy focusing on external rotation and abduction combined with NSAIDs for 8-12 weeks before considering advanced imaging. 1, 2, 3

Initial Imaging Approach

Plain radiography is the mandatory first step for any patient presenting with shoulder pain and restricted mobility 1, 3:

• Obtain a minimum three-view series: AP views in internal and external rotation, plus either axillary or scapular Y view 1, 3
• Perform radiographs with the patient upright, as supine positioning can mask shoulder malalignment 1, 3
• The axillary or scapular Y view is critical—acromioclavicular and glenohumeral pathology can be completely missed on AP views alone 1, 3

Key radiographic findings to assess 3:

• Superior migration of the humeral head (suggests rotator cuff tear)
• Joint space narrowing and osteophytes (glenohumeral osteoarthritis)
• Acromioclavicular joint changes
• Fracture or dislocation

Clinical Diagnosis Based on Presentation

The inability to place the arm behind the back (internal rotation deficit) is characteristic of adhesive capsulitis or rotator cuff pathology 4, 5:

For adhesive capsulitis 4, 5:

• Diffuse shoulder pain with restricted passive range of motion on examination (not just active limitation)
• Often associated with diabetes mellitus or thyroid disorders
• Pain typically precedes stiffness

For rotator cuff disorders 5:

• Pain specifically with overhead activities
• Weakness on empty can test and external rotation testing
• Positive impingement sign
• May have preserved passive range of motion early on

Initial Conservative Management (First 8-12 Weeks)

Begin structured exercise therapy immediately 2:

• Focus on gentle stretching and mobilization techniques targeting external rotation and abduction specifically 1, 2
• Active range of motion should be increased gradually while restoring shoulder girdle alignment and strengthening weak muscles 1
• Address scapular dyskinesis if present, as this contributes significantly to both rotator cuff and labral injuries 2

Pharmacologic management 1, 2:

• NSAIDs are recommended as first-line medication 2
• Acetaminophen or ibuprofen can be used if no contraindications 1
• Avoid corticosteroid injections initially—evidence is conflicting and they may compromise tendon biology 2

Critical pitfall: Do not use overhead pulleys during rehabilitation, as they encourage uncontrolled abduction and can worsen shoulder pain 1

When to Obtain Advanced Imaging

Reserve MRI or ultrasound for patients who fail to respond after 8-12 weeks of conservative management 2, 3:

If radiographs are noncontributory and rotator cuff tear is suspected 3:

• MRI shoulder without contrast (rating 9/9) OR ultrasound (rating 9/9) are equally appropriate 3
• Choose MRI if: large body habitus, severely restricted ROM from acute pain, suspicion of labral tears, or need for comprehensive evaluation of bone marrow and cartilage 3
• Choose ultrasound if: proximal humeral hardware present (MRI artifacts), or MRI contraindicated 3

If adhesive capsulitis is suspected with normal radiographs 3:

• MRI shoulder without contrast is usually appropriate (rating 7-9/9) 3

Reassessment Timeline and Escalation

Reassess at 8-12 weeks 2:

• Most patients show significant improvement in pain scores after 8 weeks of exercise therapy 2
• If no improvement, obtain advanced imaging at this point 2

Consider surgical referral only if 2:

• Conservative management fails after adequate 3-6 month trial 2
• Advanced imaging reveals significant full-thickness rotator cuff tear requiring repair 2
• Recurrent instability episodes despite rehabilitation 2

For concomitant rotator cuff tear with adhesive capsulitis: Single-stage arthroscopic capsular release with rotator cuff repair is effective and produces excellent outcomes 6

Special Considerations for Specific Conditions

If adhesive capsulitis is confirmed 4:

• The condition is often self-limited but can persist for years 4
• Oral prednisone may be considered if conservative measures fail 4
• Intra-articular corticosteroid injections are an option after initial conservative management 4
• Physical therapy and home exercise regimens remain the cornerstone 4

If rotator cuff pathology is confirmed 1:

• Subacromial corticosteroid injections can be used when pain is thought related to subacromial bursa or rotator cuff inflammation 1
• Botulinum toxin injections into subscapularis and pectoralis muscles may be used if pain is related to spasticity (primarily in stroke patients) 1