A 27-year-old man presents to urgent care with a gradual onset of shoulder pain that worsens with overhead activities and at night. He reports no history of trauma. The physical examination reveals tenderness over the lateral aspect of the shoulder and a positive Neer test. What is the most likely diagnosis and initial management plan for this patient?
- Rotator cuff tear; refer to the ED for an MRI
- Adhesive capsulitis; administer corticosteroid injection
- Shoulder impingement syndrome; administer NSAID injection and refer to physical therapy
- Shoulder dislocation; perform immediate reduction
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Answer: C. Pain at night and pain localizing to the anterolateral acromial area indicate shoulder impingement syndrome. The main goals in treatment of shoulder impingement syndrome are to relieve pain and to solve the mechanical problem causing functional impairment. While there is no consensus on the best management of shoulder impingement syndrome, many patients improve with anti-inflammatory medication and physical therapy. NSAID injections are preferable to oral or topical NSAIDs due to risk of gastrointestinal and renal injury (with oral NSAIDs) and unreliability of skin penetration (with topical NSAIDs). The clinical effect of intra-articular NSAID injection is similar to that of intra-articular corticosteroid injections, without the risk of long-term systemic sequelae (eg, bone, tendon, and cartilage necrosis; hyperglycemia) of corticosteroids.
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Tracey Davidoff, MD, FACP, FCUCM, has practiced Urgent Care Medicine for more than 15 years. She is Board Certified in Internal Medicine. Dr. Davidoff is a member of the Board of Directors of the Urgent Care Association and serves as Co-Editor-in-Chief of the College of Urgent Care Medicine’s “Urgent Caring” publication. She is also the Vice President of the Southeast Regional Urgent Care Association and a member of the editorial board of the Journal of Urgent Care Medicine. At EB Medicine, Dr Davidoff is Editor-In-Chief of Evidence-Based Urgent Care, and co-host of the Urgentology podcast.
