Management of Degenerative Changes in the Right Shoulder with Impingement

Initial Conservative Management

The American College of Radiology recommends initiating conservative management with physical therapy, NSAIDs, and activity modification before considering more invasive interventions for patients with degenerative changes in the right AC joint and shoulder joint with narrowing of the subacromial space and clinical impingement 1, 2
Physical therapy should begin with range of motion and strengthening exercises focusing on the rotator cuff and posterior shoulder girdle muscles to improve shoulder mechanics and reduce impingement 3, 2
Active range of motion should be increased gradually while restoring alignment and strengthening weak muscles in the shoulder girdle 3

The American College of Radiology suggests starting with acetaminophen as first-line oral analgesic due to its favorable safety profile 4
If inadequate relief, use NSAIDs at the lowest effective dose for the shortest duration possible 4

Modify daily activities to reduce stress on the shoulder joint during the healing process 2

Subacromial corticosteroid injections can be used when pain is related to inflammation of the subacromial region (rotator cuff or bursa) 3, 2

The American College of Radiology recommends MRI shoulder without contrast to further evaluate the extent of rotator cuff pathology, labral tears, and other soft tissue abnormalities if symptoms persist despite conservative management 5, 6
Ultrasound is an alternative to MRI for evaluating the rotator cuff and biceps tendon, depending on local expertise 5

The American Academy of Orthopaedic Surgeons recommends surgical referral for persistent pain and functional limitation despite adequate conservative management 7
Evidence of significant rotator cuff tear on imaging that correlates with clinical symptoms is an indication for surgical referral 7

Rotator cuff repair is a surgical option if a significant tear is present 7
AC joint resection is a surgical option if AC joint arthritis is a significant contributor to symptoms 2

Proper positioning of the shoulder during rehabilitation is essential to prevent further impingement and promote healing 3

Failing to obtain proper radiographic views (AP views in internal and external rotation and an axillary or scapula-Y view) when evaluating shoulder pain 1
Not addressing scapular dyskinesis, which can contribute to impingement symptoms 2
Neglecting to evaluate and treat contributing factors such as poor posture or muscle imbalances 4