What is the recommended clinical pathway for evaluating and treating suspected subacromial impingement in a patient aged 65 years or older with typical geriatric comorbidities such as cardiovascular disease, hypertension, chronic kidney disease, diabetes, osteoporosis, gastrointestinal ulcer disease, cognitive impairment, and polypharmacy?

Clinical Pathway for Evaluating and Treating Subacromial Impingement in Geriatric Patients

In geriatric patients aged ≥65 years with suspected subacromial impingement, begin with a comprehensive geriatric assessment including frailty screening, polypharmacy review, and cognitive evaluation before proceeding with standard shoulder-specific diagnostic testing, as these factors fundamentally alter treatment selection and outcomes. 1

Initial Geriatric-Specific Assessment

Mandatory Screening Components

• Screen for frailty using validated tools such as the Clinical Frailty Scale or modified Frailty Index, as frailty independently predicts adverse outcomes and should guide treatment intensity 1

• Perform comprehensive medication review to identify polypharmacy (common in this population), focusing on medications that may contribute to falls, impair healing, or interact with planned treatments including NSAIDs, corticosteroids, anticoagulants, and antiplatelets 1

• Assess cognitive function using validated screening tools, as unrecognized cognitive impairment interferes with ability to perform prescribed exercises and self-management strategies 1

• Evaluate for sarcopenia and malnutrition, which are highly prevalent in older adults and directly impact rotator cuff integrity and healing capacity 1

• Screen for fall risk using targeted history focusing on visual impairment, peripheral neuropathy, orthostatic hypotension, and prior falls, as shoulder pain and weakness increase fall risk 1

Shoulder-Specific Diagnostic Evaluation

Clinical Examination

• Combine multiple clinical tests rather than relying on a single maneuver, as no single test is pathognomonic for subacromial impingement 2, 3

• Prioritize high-sensitivity tests first: Hawkins test (92.1% sensitivity), Neer test (88.7% sensitivity), and horizontal adduction test (82.0% sensitivity) to rule out subacromial pathology 3

• Use high-specificity tests for confirmation: Drop arm test (97.2% specificity), Yergason test (86.1% specificity), and painful arc test (80.5% specificity) when initial screening is positive 3

• Perform subacromial injection test as the reference standard—temporary pain relief after lidocaine injection confirms the diagnosis 2, 3

Imaging Protocol

• Obtain standard radiographs initially to assess acromial morphology, acromial index, critical shoulder angle, and exclude other pathology 2, 4, 5

• Proceed to ultrasound examination after 6 weeks of persistent symptoms as the recommended first-line advanced imaging to exclude rotator cuff rupture 2

• Reserve MRI for cases requiring assessment of associated intraarticular abnormalities, joint effusion, bone marrow edema, or when ultrasound is inconclusive 4, 5

Treatment Algorithm for Geriatric Patients

First-Line Conservative Management (Weeks 0-6)

• Initiate low-intensity, high-frequency exercise therapy combining eccentric training, attention to relaxation and posture, and myofascial trigger point treatment with stretching 2

• Avoid strict immobilization and aggressive mobilization techniques, as these are not recommended and may worsen outcomes in older adults 2

• Prescribe analgesics cautiously for acute pain, carefully considering renal function, cardiovascular disease, and GI ulcer risk given the high prevalence of these comorbidities 1

• Avoid NSAIDs in patients with chronic kidney disease, cardiovascular disease, or GI ulcer disease due to increased risk of adverse events; consider acetaminophen as safer alternative 1

Second-Line Intervention (Weeks 6-12)

• Administer subacromial corticosteroid injection for persistent or recurrent symptoms after initial conservative measures fail 2, 5

• Consider occupational interventions when complaints persist beyond 6 weeks, particularly important in older adults who may need workplace or home modifications 2

• Refer to specialized rehabilitation unit for chronic, treatment-resistant cases with pain-perpetuating behavior 2

Special Considerations for Calcific Tendinosis

• Treat tendinosis calcarea with extracorporeal shockwave therapy (ESWT) or ultrasound-guided needling (barbotage) when identified on imaging 2

Critical Geriatric-Specific Modifications

Medication Management Pitfalls

• Review and potentially deprescribe cardiovascular medications that may impair healing or increase fall risk, balancing benefits against quality of life 1

• Screen specifically for beta-blockers, anticoagulants, and antiplatelet agents that increase bleeding risk with injections and may require temporary adjustment 1

• Assess for drug-drug interactions when adding analgesics or anti-inflammatory medications to existing polypharmacy regimens 1

Exercise Prescription Adaptations

• Start at lower intensity than standard protocols if frailty, sarcopenia, or deconditioning is present 1

• Incorporate fall prevention strategies into exercise programs, including balance training and environmental modifications 1

• Involve caregivers in exercise education when cognitive impairment is present to ensure adherence 1

Surgical Considerations

• There is no convincing evidence that surgical treatment is more effective than conservative management for subacromial impingement 2

• Reserve surgery only for refractory cases after at least 2 years of conservative treatment (which yields satisfactory results in 60% of cases) and only when rotator cuff continuity is preserved 2, 5

• Assess frailty status before any surgical intervention, as frailty is highly predictive of 30-day mortality and complications for all procedures in older adults 1

• Obtain comprehensive geriatric assessment (CGA) before considering surgery in frail patients to provide safe and goal-concordant care 1

Monitoring and Follow-Up

• Reassess at 6-week intervals with repeat physical examination and functional assessment 2, 5

• Reevaluate medication appropriateness at each visit, particularly after care transitions or hospitalizations 1

• Monitor for treatment-related complications including injection site reactions, hyperglycemia from corticosteroids (especially in diabetic patients), and exercise-related injuries 1

• Establish shared decision-making regarding treatment goals, prioritizing quality of life, functional capacity, and symptom control over anatomical perfection 1