What is the best course of treatment for a patient with right shoulder pain and positive empty can and liftoff test results, likely indicating rotator cuff disease or tendinopathy?

Treatment for Right Shoulder Pain with Positive Empty Can and Liftoff Tests

Begin with a structured 8-12 week trial of exercise therapy combined with NSAIDs before considering any invasive interventions, as this conservative approach demonstrates equivalent outcomes to surgery for rotator cuff-related shoulder pain. 1, 2

Initial Conservative Management (Weeks 0-12)

Exercise Therapy

• Initiate a progressive exercise program immediately as the primary treatment modality, which can be either supervised physiotherapy or a structured home program 1, 3
• All three types of exercise programs show effectiveness: open chain resisted band exercises, closed chain exercises, and range of movement exercises produce significant reductions in pain and disability 4
• Exercise therapy demonstrates beneficial effects in decreasing pain and improving function, with significant improvements in pain scores after 8 weeks and functional improvements after 3 months 1
• The mechanical diagnosis and therapy (MDT) approach using repeated end-range movements can abolish shoulder pain and restore motion within 2 weeks, even with positive rotator cuff signs 5

Pharmacologic Management

• Prescribe NSAIDs for short-term pain relief as part of initial conservative management 1, 3
• NSAIDs provide acute pain relief but do not alter long-term outcomes 3
• Topical NSAIDs are effective alternatives with potentially fewer systemic side effects 3

Activity Modification

• Reduce repetitive overhead activities to decrease loading on the damaged tendon while maintaining some activity level 3
• Relative rest prevents further damage and promotes healing, though complete immobilization should be avoided 3

Critical Pitfall: Avoid Corticosteroid Injections Initially

Do not use subacromial corticosteroid injections as first-line treatment for several important reasons:

• Evidence for their use is inconclusive, with one level II study showing no significant difference compared to lidocaine alone 3
• While they may provide short-term pain relief, they do not alter long-term outcomes 3
• Potential adverse effects on rotator cuff tendon biology and healing capacity exist, though definitive evidence is lacking 3, 1

Imaging Considerations

Imaging is not routinely indicated unless specific criteria are met 3:

• Obtain plain radiographs to assess for fracture, shoulder alignment, and bony pathology 1
• Reserve MRI or ultrasound for patients who fail to respond to 8-12 weeks of conservative treatment or if findings would change management 3, 1
• MRI without contrast is preferred for evaluating rotator cuff pathology and soft-tissue injuries 1
• Ultrasound is an equivalent alternative depending on local expertise 1

Reassessment at 8-12 Weeks

If Significant Improvement:

• Continue conservative management with progressive exercise advancement 1
• Gradually increase activity levels as tolerated 3

If Inadequate Response:

• Obtain advanced imaging (MRI or ultrasound) to evaluate for full-thickness rotator cuff tear 1
• Consider ultrasound-guided needle aspiration and lavage if calcific tendinopathy is identified 6
• Reassess for red flags or alternative diagnoses 3

Surgical Referral Criteria

Surgery should only be considered after 3-6 months of failed conservative therapy 3, 1:

• The American Academy of Orthopaedic Surgeons recommends surgical review if 3 months of non-surgical management has been unsuccessful 3
• Surgery is reserved for carefully selected patients with chronic, symptomatic full-thickness tears who have failed conservative treatment 3
• Rotator cuff repair shows statistically significant less pain on shoulder range of motion and at night compared to continued non-surgical treatment in appropriate candidates 3

Additional Therapeutic Modalities (Uncertain Benefit)

The following have unclear evidence and should not replace exercise and NSAIDs as primary treatment:

• Therapeutic ultrasound, corticosteroid iontophoresis, and phonophoresis show uncertain benefit 3
• Extracorporeal shock wave therapy appears safe and effective but is expensive 3
• Orthotics and braces have no conclusive recommendations; use based on clinical experience and patient preference 3

Key Clinical Pearls

• Positive empty can and liftoff tests indicate rotator cuff involvement but do not distinguish between tendinopathy, partial tears, or full-thickness tears 7
• Exercise therapy confers at least equivalent benefit to surgery for subacromial pain syndrome, rotator cuff tendinopathy, partial thickness tears, and atraumatic full-thickness tears 2
• Manual therapy should only be used in conjunction with exercise, not as standalone treatment 3
• Most patients with rotator cuff-related shoulder pain can be managed successfully without surgical intervention 6