What is the appropriate treatment plan for a patient with intermittent left shoulder pain for one year, provoked by overhead elevation of the arm, who has not used any prior medication?

Treatment Plan for Chronic Shoulder Pain Provoked by Overhead Elevation

Begin with a structured physical therapy program focused on rotator cuff and scapular stabilizer strengthening—this is the most appropriate first-line intervention for subacromial impingement syndrome, which your clinical presentation strongly suggests. 1

Immediate Diagnostic Steps

Before initiating treatment, obtain plain radiographs of the shoulder in three views (anteroposterior in internal rotation, anteroposterior in external rotation, and axillary or scapular-Y view) to rule out fractures, dislocations, or degenerative changes that would alter management. 2, 1, 3 This is mandatory even without trauma history, as your age group (over 35-40 years) is at risk for rotator cuff disease and degenerative pathology. 4, 1

Do not order MRI at this initial evaluation—imaging beyond plain films is only indicated if symptoms persist after 3-6 months of adequate conservative therapy, if there is marked strength loss suggesting full-thickness tear, or if surgical planning becomes necessary. 1

Clinical Diagnosis

Your presentation—pain triggered specifically by arm elevation for one year—indicates subacromial impingement syndrome with rotator cuff tendinopathy. 1 The supraspinatus tendon becomes compressed under the coracoacromial arch during abduction between 70-120 degrees, creating the characteristic pain arc you're experiencing. 1

First-Line Treatment Protocol

Physical Therapy (Primary Intervention)

Refer immediately to physical therapy—evidence shows 80% of patients achieve full recovery within 3-6 months with supervised rehabilitation. 1 The program must include:

• Complete rest from overhead activities until you are asymptomatic 1
• Range of motion exercises through stretching and mobilization, focusing specifically on external rotation and abduction to prevent frozen shoulder 1, 3
• Eccentric strengthening exercises for the rotator cuff once pain-free motion is achieved—these are specifically recommended to promote tendinopathy healing 1
• Scapular stabilizer strengthening to address underlying biomechanical dysfunction 1

Critical: Avoid overhead pulley exercises—these encourage uncontrolled abduction and can worsen rotator cuff pathology. 1, 3

Pain Management

Since you have not used any medication, start with:

1. Acetaminophen 650-1000 mg every 6 hours as needed (maximum 4 grams daily)—this provides pain relief comparable to NSAIDs without gastrointestinal toxicity and is first-line for mild-to-moderate pain. 3, 5

2. If acetaminophen fails after 1-2 weeks, add ibuprofen 400-600 mg every 6-8 hours with food (maximum 2400 mg daily). 2, 6 However, recognize that NSAIDs carry significant risks including gastrointestinal bleeding, cardiovascular events, and kidney injury—use the lowest effective dose for the shortest duration possible. 6

3. Consider topical NSAIDs or capsaicin cream as adjuncts to reduce systemic medication exposure. 3

Corticosteroid Injection (If Inadequate Response)

If pain remains severe after 4-6 weeks of physical therapy and oral analgesics, proceed with subacromial corticosteroid injection—this is appropriate when pain is related to inflammation of the subacromial region (rotator cuff or bursa). 2, 1

• Inject methylprednisolone acetate 20-80 mg into the subacromial space using sterile technique. 7
• This provides significant pain relief and facilitates participation in physical therapy. 1
• Effects typically last several weeks to months. 2

Timeline and Monitoring

• Weeks 0-2: Begin physical therapy, start acetaminophen, complete radiographs
• Weeks 2-6: Progress therapy intensity, add NSAIDs if needed
• Weeks 6-12: Consider corticosteroid injection if inadequate progress
• Month 3-6: Continue supervised rehabilitation with gradual return to overhead activities

Only consider orthopedic referral if symptoms persist after 3-6 months of adequate conservative management—surgery is required in only 9% of subacromial impingement cases. 1

Red Flags Requiring Immediate Specialist Referral

Stop and refer urgently if you develop:

• Neurological deficits (numbness, tingling, weakness radiating down the arm in dermatomal pattern—suggests cervical radiculopathy) 4, 3
• Marked weakness with inability to actively abduct the arm (suggests full-thickness rotator cuff tear) 1
• Fever or constitutional symptoms (suggests septic arthritis) 3
• Night pain that awakens you from sleep (may indicate more serious pathology) 1

Critical Pitfalls to Avoid

• Do not assume this is "just muscle tension" without ruling out structural pathology with imaging, especially given the one-year duration. 4
• Do not use NSAIDs long-term—the frequency of adverse events increases substantially with prolonged use. 3, 6
• Do not delay physical therapy referral—early structured rehabilitation is the cornerstone of successful conservative management. 1
• Do not perform aggressive stretching or strengthening before achieving pain-free range of motion—this can worsen inflammation. 1