Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with chronic, activity-related right shoulder pain, localized to the lateral deltoid region. Symptoms exacerbated by overhead reaching, lifting, and night pain when lying on the affected side. No history of acute trauma. Reports weakness and stiffness, with symptoms progressively worsening over [Duration].
Clinical Examination Findings
Right shoulder inspection reveals no atrophy or deformity. Palpation demonstrates tenderness over the greater tuberosity and subacromial space. Active ROM shows painful arc between 60-120 degrees of abduction. Passive ROM is full but painful at end-range. Positive Neer and Hawkins-Kennedy impingement signs. Rotator cuff strength testing (Jobe’s/Empty Can) reveals 4+/5 strength with pain. Neurovascular status intact distally.
Treatment Protocol
Initiate conservative management: Activity modification, avoidance of overhead activities, and NSAIDs for inflammation control. Referral to physical therapy for rotator cuff strengthening and scapular stabilization exercises. Consider subacromial corticosteroid injection if symptoms persist. Follow-up in [Timeframe] to reassess clinical status.