How should a 23-year-old male with clicking of the shoulder during range of motion be managed?

Management of Shoulder Clicking in a 23-Year-Old Male

Start with plain radiographs (AP views in internal/external rotation plus axillary or scapula-Y view) to rule out structural pathology, then proceed with conservative management focused on rotator cuff and scapular stabilizer strengthening if imaging is unremarkable. 1

Initial Diagnostic Approach

Imaging Strategy

For a young adult with mechanical symptoms like clicking during range of motion, radiographs are the appropriate first-line imaging 1. The standard trauma series should include:

• Anteroposterior views in internal and external rotation
• Axillary or scapula-Y view (critical for detecting subtle instability or malalignment that AP views alone may miss)

Important caveat: While the ACR guidelines emphasize traumatic shoulder pain, the imaging principles apply here since clicking suggests a mechanical derangement that could represent early soft tissue pathology 2.

Clinical Assessment Details

Look specifically for:

• Pain location and timing: Does clicking occur with overhead activities? During specific phases of motion? 3
• Weakness patterns: Focal weakness with abduction/rotation suggests rotator cuff involvement 3
• Scapular dyskinesis: Observe for abnormal scapular positioning or winging during arm elevation 4
• Range of motion deficits: External rotation limitations are particularly significant 5

Most Likely Diagnoses in This Age Group

In a 23-year-old male, clicking without trauma most commonly represents:

1. Subacromial subdeltoid (SASD) bursitis - can cause clicking/snapping even without pain 6
2. Labral pathology - SLAP lesions or other labral tears 2
3. Rotator cuff dysfunction with secondary impingement - particularly in overhead athletes 3
4. Scapulothoracic dysfunction - altered scapular mechanics 6, 4

Conservative Management Protocol

If radiographs are normal, initiate a structured rehabilitation program 7:

Phase 1: Initial Management (Weeks 1-4)

• Rotator cuff strengthening: Focus on isolated contraction training of deep stabilizers before loaded activities 4
• Scapular stabilizer training: Target serratus anterior and trapezius force couples 4
• Range of motion exercises: Emphasize external rotation and abduction to prevent adhesive capsulitis 5
• Avoid overhead pulleys: These encourage uncontrolled abduction and can worsen symptoms 5

Phase 2: Progressive Loading (Weeks 4-12)

• Multimodal care: Combine heat/cold, joint mobilization, and progressive ROM exercises 7
• Cervicothoracic manipulation/mobilization: Consider if there's associated neck stiffness or restricted cervicothoracic movement 7
• Low-level laser therapy: Evidence supports this for shoulder pain of any duration 7

Monitoring for Red Flags

Reassess at each visit for:

• Progressive weakness (suggests evolving rotator cuff tear)
• Night pain awakening from sleep (rotator cuff pathology) 8
• Inability to hold arm in elevated position (significant rotator cuff involvement) 8
• Development of instability symptoms (recurrent subluxation sensation)

When to Advance Imaging

Order MRI if:

• Symptoms persist beyond 6-8 weeks of conservative management
• Progressive weakness develops
• Clinical examination suggests labral tear or significant rotator cuff pathology
• Patient is an overhead athlete with persistent mechanical symptoms 3

MRI is superior to CT for soft tissue evaluation and can diagnose labral tears, rotator cuff tears (full and partial thickness), and bursitis 2.

Special Consideration for Athletes

If this patient participates in throwing sports or overhead activities 3:

• Complete rest from throwing until asymptomatic
• Biomechanical assessment: Coordinate with coaches to identify faulty mechanics
• Gradual return protocol: 1-3 months progressive throwing program emphasizing proper mechanics
• Return to competition: Only after completing functional throwing program without symptoms 3

Key Pitfall to Avoid

Do not dismiss painless clicking as benign without proper evaluation. While many young adults have asymptomatic clicking, this can represent early labral pathology or rotator cuff dysfunction that may progress if the underlying biomechanical issues aren't addressed 6. The absence of pain doesn't eliminate the need for proper strengthening and motor control training 4.