A 52-year-old with three-week left shoulder pain after heavy yard work, pain on abduction >90°, 4/5 strength, stable shoulder, and positive Hawkins impingement test—what is the most appropriate next step: immobilization with physical therapy, corticosteroid injection, MRI, or orthopedic referral?

Management of Subacromial Impingement Syndrome

Referral for physical therapy is the most appropriate next step for this 52-year-old patient with clinical subacromial impingement syndrome. 1

Clinical Reasoning

This patient presents with the classic triad of rotator cuff tendinopathy/subacromial impingement:

• Age over 35-40 years (the predominant age group for rotator cuff pathology) 2
• Pain with abduction >90° (the classic impingement arc where the supraspinatus tendon passes beneath the coracoacromial arch) 1
• Positive Hawkins and Neer impingement tests (92% and 88% sensitive respectively for impingement) 1

The 4/5 strength with abduction past 90° indicates rotator cuff involvement without complete tear, and the three-week duration following overuse activity confirms this is a chronic degenerative tendinopathy rather than acute inflammation. 1

Why Physical Therapy First

Conservative management with physical therapy is the evidence-based first-line treatment for rotator cuff tendinopathy, with approximately 80% of patients achieving full recovery within 3-6 months. 1 The rehabilitation program should include:

• Complete rest from aggravating overhead activities until asymptomatic 2
• Range of motion exercises focusing on external rotation and abduction to prevent frozen shoulder 2
• Progressive strengthening of rotator cuff and scapular stabilizers once pain-free motion is achieved 2
• Eccentric strengthening exercises specifically, which are recommended for tendinopathy recovery 1

Why Not the Other Options

Immobilization is contraindicated in this case. Immobilization is reserved for acute traumatic injuries in younger patients (<20 years) with instability requiring capsulolabral healing, not for overuse tendinopathy in a 52-year-old. 3 Prolonged immobilization in middle-aged patients risks developing adhesive capsulitis. 2

Corticosteroid injection should be reserved for more severe cases that fail initial conservative therapy. While subacromial corticosteroid injections are effective (91% satisfaction at 4 weeks, 88% at 1 year), 4, 5 they are not first-line treatment. Studies show injections provide short-term pain relief and improved range of motion, 6, 5 but physical therapy addresses the underlying biomechanical dysfunction (scapular dyskinesis, rotator cuff weakness) that caused the impingement. 2 If physical therapy fails after 4-6 weeks, corticosteroid injection becomes appropriate. 4

MRI is not indicated at this stage. The diagnosis is clear from clinical examination alone (positive impingement signs, characteristic pain pattern, appropriate age). 1 MRI would be appropriate if: (1) symptoms fail to improve after 3-6 months of conservative therapy, (2) there is concern for full-thickness rotator cuff tear (which this patient's 4/5 strength argues against), or (3) surgical planning is needed. 1, 2

Orthopedic referral is premature. Surgery is reserved for patients who fail a well-managed 3-6 month conservative treatment trial. 1 Only 9% of patients with impingement syndrome require surgical referral after failed conservative management. 4

Critical Management Points

• Document that passive range of motion is preserved to distinguish this from adhesive capsulitis, where passive motion would also be limited 2
• Avoid overhead pulley exercises initially, as uncontrolled abduction can worsen rotator cuff pathology 2
• Reassess at 4-6 weeks: if no improvement, consider adding corticosteroid injection (40mg triamcinolone with lidocaine) 4, 5
• Red flag for surgical referral: if symptoms persist despite injection and 3-6 months of physical therapy, suspect partial or full-thickness rotator cuff tear requiring MRI and orthopedic evaluation 4