What is an appropriate treatment plan for an adult with shoulder pain that includes ordering standard shoulder radiographs (AP, scapular Y‑view, and axillary lateral), prescribing meloxicam, advising ice, heat, and rest, referring to physical therapy, and arranging follow‑up?

Treatment Plan for Shoulder Pain: Radiographs, Meloxicam, Physical Therapy, and Follow-Up

Imaging Protocol

Order a standard three-view shoulder radiograph series consisting of anteroposterior (AP) views in both internal and external rotation plus either an axillary lateral or scapular Y-view. 1, 2, 3

• The American College of Radiology mandates a minimum of three views with two being orthogonal for any shoulder pain evaluation 1, 3
• The axillary or scapular Y-view is essential because AP views alone miss up to 50% of glenohumeral dislocations and acromioclavicular joint pathology 2, 3
• Ensure radiographs are obtained with the patient upright rather than supine, as shoulder malalignment can be significantly underrepresented on supine imaging 2, 3
• These views effectively demonstrate joint alignment abnormalities, calcific tendinitis, bone erosions, and acromioclavicular joint pathology 3

Pharmacologic Management

Prescribe meloxicam 7.5 mg orally once daily, with the option to increase to 15 mg daily if pain control is inadequate after 3–5 days. 4, 5

• Meloxicam is a moderately selective NSAID that offers the most acceptable balance between efficacy and safety for the majority of patients, with proven lower gastrointestinal and cardiovascular risk compared to nonselective NSAIDs and COX-2 inhibitors 4
• The standard dosing regimen is 7.5–15 mg orally daily for 14 days, which has demonstrated efficacy in treating musculoskeletal pain syndromes 5
• For severe acute pain, consider starting with intramuscular meloxicam 15 mg (1.5 mL) daily for 3–5 days, then transition to oral 7.5–15 mg for the remainder of the 14-day course 5
• Meloxicam has good compatibility with low-dose aspirin if the patient requires cardiovascular prophylaxis 4

Activity Modification and Home Therapy

Instruct the patient to completely avoid all aggravating activities—particularly overhead movements, abduction beyond 90°, and internal rotation—until pain-free. 2

• Apply ice for 15–20 minutes every 2–3 hours during the first 48–72 hours to reduce acute inflammation 2
• After the initial 48–72 hours, transition to heat application (warm packs or heating pad for 15–20 minutes) before stretching exercises to improve tissue extensibility 2
• Emphasize that rest from aggravating activities is the cornerstone of early conservative management and must continue until the patient becomes asymptomatic 2

Physical Therapy Referral

Refer to physical therapy immediately for a supervised rehabilitation program, as evidence-based conservative care centered on physical therapy leads to full recovery in approximately 80% of patients within 3–6 months. 2

• The physical therapy protocol should progress through three phases: (1) complete rest until pain-free, (2) range-of-motion restoration through stretching and mobilization focusing on external rotation and abduction, and (3) rotator cuff and scapular stabilizer strengthening once pain-free motion is achieved 2
• Eccentric strengthening exercises are specifically recommended to promote tendinopathy healing 2
• Instruct the therapist to avoid overhead pulley exercises, which encourage uncontrolled abduction and can worsen rotator cuff pathology 2
• The rehabilitation program should be functional, progressive, and individualized over 1–3 months 2

Follow-Up Plan

Schedule follow-up in 2 weeks to review radiograph results and assess response to initial conservative management. 2

• At the 2-week visit, reassess pain levels, range of motion, and functional limitations to determine if the current treatment plan is adequate 2, 6
• If symptoms persist despite 3–6 months of adequate conservative therapy, or if there is clinical suspicion for a full-thickness rotator cuff tear (marked strength loss), order MRI without contrast at that time 2
• Plan a second follow-up at 6–8 weeks to evaluate progress with physical therapy and consider whether corticosteroid injection is warranted for more severe cases 2
• Orthopedic referral is appropriate only after a well-managed 3–6-month trial of conservative therapy has failed, as only about 9% of patients with subacromial impingement ultimately require surgical intervention 2

Critical Pitfalls to Avoid

• Do not order MRI at initial presentation when clinical findings clearly establish the diagnosis; imaging beyond radiographs is premature before completing conservative therapy 2
• Do not rely on AP radiographs alone, as this misses posterior dislocations and AC joint separations 2, 3
• Do not refer to orthopedics prematurely before completing the 3–6-month conservative trial 2