What is the best course of treatment for a 32-year-old male patient with chronic right shoulder pain, who has a history of trauma and has been experiencing symptoms for a couple of years since an altercation, despite resting for six months and then resuming workouts, which seems to have aggravated the condition?

Management of Chronic Post-Traumatic Shoulder Pain

This 32-year-old male with chronic shoulder pain from a 2-year-old traumatic injury that worsened after resuming exercise requires immediate imaging with plain radiographs (3 views minimum), followed by MRI if radiographs are normal, and should begin a structured physical therapy program with eccentric strengthening exercises while avoiding activities that aggravate symptoms.

Initial Diagnostic Approach

Imaging Strategy

• Start with plain radiographs including anteroposterior views in internal and external rotation plus an axillary or scapula-Y view to assess for fracture, malalignment, or chronic changes from the initial trauma 1
• Proceed to MRI without contrast if radiographs are normal or show only minor abnormalities, as this effectively diagnoses rotator cuff tears, labral injuries, and other soft-tissue pathology that commonly result from traumatic shoulder injuries 1
• MR arthrography is the gold standard but requires an invasive procedure, so reserve it for cases where standard MRI findings are equivocal or surgical planning is needed 1

Key Clinical Examination Findings to Document

• Assess for rotator cuff pathology: weakness with resisted external rotation, positive impingement signs, atrophy of supraspinatus or infraspinatus muscles 2, 3
• Evaluate for instability: apprehension test, relocation test, history of shoulder "giving way" or subluxation episodes 3
• Check for labral pathology: pain with overhead activities, clicking or catching sensations 1
• Document range of motion limitations: both active and passive, comparing to contralateral side 1, 4

Treatment Algorithm

Conservative Management (First-Line for 3-6 Months)

Activity Modification and Relative Rest

• Immediately cease activities that aggravate symptoms, particularly overhead movements and heavy lifting that likely worsened his condition when he resumed working out 1
• This does not mean complete immobilization; maintain pain-free range of motion 1

Physical Therapy with Eccentric Strengthening

• Eccentric strengthening exercises are the most effective conservative treatment and may reverse degenerative tendon changes 1
• Supervised rehabilitation program is superior to self-directed exercise for chronic cases 1
• Duration should be at least 6-12 weeks before assessing response 4

Pain Management

• NSAIDs for short-term pain relief (7-14 days maximum), though they do not alter long-term outcomes 1
• Acetaminophen 1000mg every 6 hours is equally effective for musculoskeletal pain and has fewer side effects in young patients 1
• Avoid chronic opioid use given the 2-year duration of symptoms and risk of dependence 1

Corticosteroid Injection

• Subacromial corticosteroid injection may provide better acute pain relief than oral NSAIDs but does not change long-term outcomes 1
• Consider this as an adjunct to physical therapy if pain limits participation in rehabilitation 4
• The injection site depends on the specific diagnosis: subacromial for rotator cuff pathology, intra-articular for labral or glenohumeral issues 4

Surgical Referral Indications

Refer to orthopedic surgery if:

• Symptoms persist or worsen after 3-6 months of appropriate conservative treatment 1, 4
• Imaging reveals a full-thickness rotator cuff tear in a young, active patient who desires return to full function 1
• Evidence of significant structural damage (large labral tear, recurrent instability, displaced fracture malunion) 1
• Progressive functional decline despite compliance with therapy 5, 4

Critical Pitfalls to Avoid

Do not assume this is simple tendinopathy - the traumatic mechanism 2 years ago combined with worsening after exercise resumption suggests structural damage (rotator cuff tear, labral tear, or chronic instability) rather than overuse tendinopathy 1, 3

Do not delay imaging - chronic symptoms in a young patient with known trauma history warrant investigation for repairable structural pathology before further degeneration occurs 1, 5

Do not prescribe prolonged rest alone - the 6-month rest period he already completed was insufficient, and complete rest without structured rehabilitation leads to muscle atrophy and adhesive capsulitis 1

Do not continue aggravating activities - his return to working out without proper rehabilitation likely caused progression of the initial injury 1

Prognosis Considerations

For chronic symptomatic rotator cuff tears, surgical repair remains an option even years after injury, though outcomes are better with earlier intervention 1. In one study, 81% of surgical patients reported excellent results compared to only 37% with nonsurgical treatment for chronic tears 1. However, the presence of muscle atrophy and chronic changes may limit surgical outcomes if delayed too long 1, 5.