A 52-year-old with 3-week left shoulder pain, pain on abduction >90°, 4/5 strength with abduction/flexion, positive Neer and Hawkins impingement tests, no trauma, swelling, or instability—what is the most appropriate next step?

Referral to Physical Therapy

The most appropriate next step is referral to physical therapy (option d). This 52-year-old patient presents with classic subacromial impingement syndrome—pain with abduction >90°, positive Neer and Hawkins tests, preserved strength (4/5), and no history of acute trauma—and evidence-based guidelines strongly recommend supervised physical therapy as first-line management, with 80% of patients achieving full recovery within 3–6 months of conservative care. 1

Why Physical Therapy is the Correct Initial Management

Conservative management centered on physical therapy is the standard of care for subacromial impingement syndrome in this clinical scenario. 1 The clinical presentation is diagnostic:

• Pain intensifying beyond 90° abduction reflects the classic "impingement arc" where the supraspinatus tendon compresses under the coracoacromial arch 1
• Positive Hawkins test (92% sensitive) and Neer test (88% sensitive) strongly support the diagnosis 1, 2
• Preserved 4/5 strength indicates rotator cuff involvement without complete tear, consistent with chronic degenerative tendinopathy rather than acute rupture 1
• Age >35 years makes rotator cuff disease and impingement the predominant pathology, not instability 1

The rehabilitation protocol should incorporate:

• Complete rest from aggravating activities until asymptomatic 1
• Stretching and mobilization to improve range of motion, especially external rotation and abduction 1
• Eccentric strengthening exercises for the rotator cuff, which are specifically recommended for tendinopathy healing 1
• Scapular stabilizer strengthening once pain-free motion is achieved 1, 2

Why Other Options Are Inappropriate at This Stage

Immobilization (option a) is contraindicated because it risks developing adhesive capsulitis (frozen shoulder) and does not address the underlying rotator cuff weakness and scapular dyskinesis that perpetuate impingement. 1, 2

Corticosteroid injection (option b) targets the wrong anatomical structure. While subacromial (not glenohumeral) corticosteroid injection can be considered for impingement syndrome 3, it is adjunctive therapy that still requires rehabilitation focusing on rotator cuff and scapular strengthening. 3 Injection without addressing the biomechanical dysfunction provides only temporary relief and does not correct the underlying pathology. 1

MRI (option c) is not indicated at initial presentation when clinical findings clearly establish the diagnosis of subacromial impingement. 1 Imaging becomes appropriate only if:

1. Symptoms persist despite 3–6 months of adequate conservative therapy
2. There is clinical suspicion for full-thickness rotator cuff tear (marked strength loss, not present here with 4/5 strength)
3. Imaging is needed for surgical planning 1

Orthopedic referral (option e) is premature before completing a well-managed 3–6 month trial of conservative therapy. 1 Surgery is reserved for patients who fail conservative management, and only approximately 9% of individuals with subacromial impingement ultimately require surgical referral. 1

Critical Diagnostic Considerations

This patient's age (52 years) is a key factor. In patients over 35–40 years, the examination and management should focus on rotator cuff disease, degenerative changes, and impingement syndrome, which are the most common disorders in this age group. 1 In contrast, patients under 35 years require comprehensive instability assessment as their primary pathology. 1

The 3-week duration following heavy yard work suggests chronic undersurface rotator cuff wear from repetitive eccentric stress on the supraspinatus and external rotators, a common mechanism in this age group. 1, 2 The absence of acute trauma does not exclude significant pathology, particularly in patients over 35 where degenerative changes can manifest after seemingly minor overuse. 1

Common Pitfalls to Avoid

Do not overlook scapular dyskinesis, which is a primary contributor to impingement that must be addressed in treatment. 2 Poor scapular coordination during arm elevation contributes to impingement by failing to properly rotate upward and tilt posteriorly, perpetuating the compression of rotator cuff structures. 2

Avoid overhead pulley exercises, which encourage uncontrolled abduction and can worsen rotator cuff pathology. 1 This is a common error in self-directed or poorly supervised rehabilitation programs.

Do not assume that preserved strength (4/5) rules out significant rotator cuff pathology. This strength level is consistent with chronic degenerative tendinopathy and partial-thickness tears, both of which respond well to conservative management. 1