What is the appropriate initial management for a 1‑month history of left shoulder pain (pain score 4/10) with limited active abduction and no swelling?

Initial Management of Chronic Shoulder Pain with Limited Abduction

Begin with standard three-view radiography (anteroposterior views in internal and external rotation plus axillary or scapular-Y view) to exclude fracture, dislocation, or significant bony pathology, followed by conservative management with structured exercise therapy as the primary treatment. 1

Immediate Diagnostic Approach

Required Initial Imaging

• Obtain radiographs as the mandatory first imaging step to rule out fracture, dislocation, glenohumeral malalignment, or significant degenerative changes that would alter management 1
• Radiographs should include minimum three views: AP in internal rotation, AP in external rotation, and axillary lateral or scapular-Y view 1
• Perform imaging upright rather than supine, as shoulder malalignment can be underrepresented on supine films 1

When to Obtain Advanced Imaging

• MRI is NOT indicated initially for this presentation unless radiographs are noncontributory and symptoms persist despite 6-8 weeks of conservative management 1, 2
• MRI becomes the procedure of choice only when evaluating for occult pathology after failed conservative treatment, as it best depicts rotator cuff, labral, and soft tissue structures 1

Primary Treatment Strategy

Exercise-Based Rehabilitation Protocol

• Implement graduated, supervised exercise therapy as first-line treatment, which demonstrates equivalent outcomes to surgery for rotator cuff-related shoulder pain including impingement syndrome, rotator cuff tendinopathy, and partial-thickness tears 2
• Exercise programs should include four core components: range of motion exercises, flexibility/stretching, progressive strengthening (particularly rotator cuff and scapular stabilizers), and manual therapy techniques 3
• Frequency should be 3-5 sessions per week with both supervised and home-based components 3

Pain Management

• Start acetaminophen 650-1000 mg every 6 hours (maximum 4 grams daily) as first-line analgesic 4
• NSAIDs can be used short-term (7-14 days) for pain control but avoid prolonged use due to gastrointestinal, renal, and cardiovascular risks 4, 5
• Consider subacromial corticosteroid injection if pain significantly limits participation in physical therapy, as early injection may shorten overall symptom duration 6

Expected Timeline and Monitoring

Conservative Management Duration

• Continue structured exercise therapy for minimum 6-8 weeks before considering alternative interventions, as most patients with rotator cuff-related shoulder pain achieve successful outcomes comparable to surgery with conservative treatment 2
• Monitor for progressive improvement in pain (measured on 0-10 scale), active range of motion (particularly abduction), and functional activities 3

Red Flags Requiring Urgent Reassessment

• Development of neurological deficits in the upper extremity mandates urgent evaluation 4
• Acute worsening of pain with inability to perform activities of daily living despite appropriate analgesia 5
• Night pain that progressively worsens and disrupts sleep consistently 5

Indications for Specialist Referral

Orthopedic Consultation Warranted When:

• Radiographs demonstrate unstable or significantly displaced fractures 4
• Failure to improve after 8-12 weeks of appropriate conservative management including structured exercise therapy 2
• Suspected full-thickness rotator cuff tear based on profound weakness (not just pain-limited weakness) with active abduction or external rotation 2
• Joint instability or recurrent subluxation episodes 4

Common Pitfalls to Avoid

• Do not proceed directly to MRI without obtaining radiographs first, as this violates evidence-based imaging algorithms and may miss fractures or dislocations requiring different management 1
• Avoid labeling this as "impingement syndrome" diagnostically, as this term presumes a specific anatomical pathology that cannot be reliably isolated on clinical examination and may lead to inappropriate surgical intervention 7
• Do not recommend surgery without adequate trial of conservative management (minimum 6-8 weeks), as exercise therapy demonstrates equivalent outcomes to surgical intervention for most rotator cuff-related conditions 2
• Avoid prolonged immobilization or complete rest, as this worsens outcomes; controlled, graduated movement is therapeutic 5, 3