What are the differential diagnoses for shoulder pain in a 68-year-old male with repetitive motion, no deformity or recent trauma, and increased pain with pushups?

Differential Diagnoses for Shoulder Pain in a 68-Year-Old Male with Repetitive Motion

In a 68-year-old male with repetitive motion-related shoulder pain exacerbated by pushups and no trauma, the primary differential diagnoses are rotator cuff tendinopathy or tear, subacromial bursitis, and acromioclavicular joint osteoarthritis, with rotator cuff pathology being most likely given the age and mechanism. 1, 2

Age-Specific Diagnostic Framework

Primary Considerations (Most Likely)

Rotator cuff disease is the predominant cause of shoulder pain in patients over 35-40 years and should be your leading diagnosis. 1, 2

• Rotator cuff tendinopathy/tear presents with pain during overhead activities and weakness, particularly with pushup movements that load the rotator cuff eccentrically. 3, 4
• The repetitive motion history suggests chronic undersurface rotator cuff wear from repetitive eccentric stress on the supraspinatus and external rotators. 3
• A clinical decision rule supporting rotator cuff tears includes: pain with overhead activity, weakness on empty can test, weakness on external rotation testing, and positive impingement sign. 4
• Pain typically occurs during the deceleration phase of repetitive movements when the rotator cuff muscles work eccentrically to control motion. 3

Subacromial-subdeltoid bursitis commonly coexists with rotator cuff pathology in this age group. 5

• Presents as anterolateral shoulder pain aggravated by overhead activities and pushup-type movements. 5
• Often secondary to rotator cuff dysfunction rather than a primary process. 3

Secondary Considerations

Acromioclavicular joint osteoarthritis is common in older patients with repetitive overhead use. 4, 5

• Presents with superior shoulder pain and tenderness directly over the AC joint. 4
• Pain is reproduced with cross-body adduction testing. 4
• Pushups can aggravate AC joint pathology through compression forces. 4

Glenohumeral osteoarthritis should be considered in patients over 50 years. 4

• Typically presents as gradual onset pain with progressive loss of motion. 4
• More likely if there is restricted passive range of motion on examination. 1

Biceps tendinopathy can occur with repetitive shoulder use. 5

• Pain is typically anterior and may be reproduced with resisted supination or Speed's test. 5
• Often occurs in conjunction with rotator cuff pathology. 5

Less Likely but Important to Exclude

Adhesive capsulitis can be associated with diabetes and thyroid disorders. 4

• Clinical presentation includes diffuse shoulder pain with restricted passive range of motion on examination—this is the key distinguishing feature. 4
• Less likely given the specific aggravation with pushups rather than global motion restriction. 4

Cervical radiculopathy can refer pain to the shoulder region. 1

• Screen for neurological symptoms including numbness, tingling, weakness, or radiation down the arm. 1
• Pain pattern typically does not correlate specifically with pushup movements. 1

Critical Diagnostic Pitfalls to Avoid

Do not assume absence of acute trauma means absence of fracture in this 68-year-old patient, as osteoporotic fractures can occur with minimal or unrecognized trauma from repetitive stress. 1, 2

Do not rely solely on mechanism of injury to exclude rotator cuff tears—chronic degenerative tears in this age group may become symptomatic without a specific traumatic event. 2, 4

Scapular dyskinesis contributes significantly to rotator cuff injury and should be assessed, as poor scapular coordination during pushups may be both cause and effect of the underlying pathology. 3

Key Physical Examination Findings to Differentiate

• Rotator cuff pathology: Focal weakness with decreased range of motion during abduction with external or internal rotation, positive empty can test, positive external rotation weakness. 3, 4
• AC joint arthritis: Tenderness directly over AC joint, positive cross-body adduction test, superior shoulder pain location. 4
• Subacromial bursitis: Painful arc between 60-120 degrees of abduction, positive impingement signs. 5
• Adhesive capsulitis: Restricted passive range of motion in multiple planes (this distinguishes it from rotator cuff disease where passive motion is preserved). 4