What is the appropriate evaluation and management for an 85‑year‑old patient presenting with shoulder and clavicular pain and reduced range of motion?

Shoulder and Clavicular Pain with Reduced ROM in an 85-Year-Old

Start with plain radiographs of the shoulder immediately—this is the mandatory first imaging study for any acute shoulder pain regardless of suspected etiology, and in an 85-year-old with clavicular involvement, you must rule out fracture before proceeding further 1.

Initial Imaging Algorithm

Plain radiographs first, always. The 2025 ACR Appropriateness Criteria are unequivocal that radiography is "usually appropriate as the initial imaging study in the setting of acute shoulder pain of any etiology" 1. In an 85-year-old, the combination of shoulder AND clavicular pain raises immediate concern for:

• Proximal humerus fracture (extremely common in this age group with osteoporosis)
• Clavicle fracture (given the specific clavicular pain mentioned)
• Scapular fracture (less common but possible)
• Glenohumeral osteoarthritis (degenerative changes are nearly universal at this age)

Next Steps Based on Radiograph Results

If Radiographs Show Fracture (Proximal Humerus, Clavicle, or Scapula):

Order CT shoulder without IV contrast immediately 1. This is the definitive next step because:

• CT provides detailed evaluation of fracture planes and displacement
• Critical for surgical planning if needed
• MRI is explicitly inferior to CT for characterizing fracture patterns 1

Exception: If the patient is NOT a surgical candidate and you suspect concurrent rotator cuff tear that might affect conservative management, MRI without contrast may be appropriate instead 1.

If Radiographs Are Normal or Show Only Degenerative Changes:

The decision tree splits based on clinical suspicion:

For suspected occult fracture (trauma history, severe pain, inability to move arm):

• CT shoulder without contrast OR MRI shoulder without contrast are both "usually appropriate" 1
• CT detects subtle nondisplaced fractures with high spatial resolution
• MRI shows bone marrow edema from occult fracture AND evaluates soft tissues simultaneously
• In an 85-year-old with reduced ROM, MRI is preferred because the ACR guidelines specifically note that "MRI might be the preferred imaging modality in cases with...restricted range of motion due to acute pain" 1

For suspected rotator cuff tear (most likely in this age group):

• MRI shoulder without contrast OR ultrasound shoulder are equivalent alternatives 1
• Both have 90-91% sensitivity and 93-95% specificity for full-thickness tears 1
• Choose MRI over ultrasound in this case because: the patient has restricted ROM (ultrasound requires patient positioning and movement), large body habitus favors MRI, and you need to evaluate other intra-articular pathology given the age 1

Clinical Context for an 85-Year-Old

Degenerative rotator cuff tears are present in 54% of asymptomatic patients aged 60+ years 2. This means imaging will likely show pathology regardless of whether it's causing the current symptoms. The key clinical questions are:

1. Is there a fracture? (Most important for morbidity/mortality—must not miss)
2. Is the rotator cuff completely torn? (Affects function and quality of life)
3. Is there adhesive capsulitis? (Common in this age, causes severe ROM restriction)
4. Is there glenohumeral osteoarthritis? (May need arthroplasty if severe)

Critical Pitfalls to Avoid

Do NOT skip plain radiographs. Even if you're "sure" it's a rotator cuff tear, you will miss fractures, dislocations, and severe arthritis that fundamentally change management 1.

Do NOT order MRI with contrast. There is "no relevant literature to support the use of MRI shoulder without and with IV contrast" in this scenario 1. The joint effusion from acute pathology provides natural contrast.

Do NOT assume imaging findings explain symptoms. One-third of people in their seventh decade have rotator cuff tears on imaging without symptoms 2. Correlation with physical examination is essential.

Do NOT rush to surgery. High-certainty evidence shows subacromial pain does not benefit from surgical intervention in most cases 3. Conservative management with education, activity modification, and watchful waiting is first-line for most shoulder pain once serious pathology is excluded 3, 4.

Conservative Management Framework

Once fracture is excluded and diagnosis established:

• Acetaminophen and oral NSAIDs (if no contraindications—watch renal function and GI risk in elderly) 4
• Structured rehabilitation with exercises (recommended across all shoulder disorders) 4
• Corticosteroid injections may be helpful for both diagnosis and treatment 5
• Most patients fully recover with minimal intervention 3

When to Refer

Reserve specialist referral for 3:

• Suspected fracture requiring surgical fixation
• Significant functional or neurologic deficit
• Persistent or worsening pain despite 6-8 weeks of conservative management
• Features suggesting infection, malignancy, or systemic inflammatory disease

The natural history is favorable for most shoulder pain in older adults, and overtreatment driven by imaging findings that don't correlate with symptoms is a major quality-of-life concern 3.