How to assess and manage a patient with shoulder pain after weight lifting, suspected of rotator cuff or related issues?

Assessment and Management of Post-Weightlifting Shoulder Pain with Suspected Rotator Cuff Injury

Begin with plain radiographs (AP, Grashey, and axillary lateral or scapular Y views) to exclude fracture and dislocation, then proceed to MRI without contrast if radiographs are normal and rotator cuff pathology is suspected. 1

Initial Clinical Assessment

Physical Examination Components

• Measure active and passive range of motion using a goniometer for forward flexion, abduction, and external rotation 2
• Test rotator cuff strength with specific maneuvers (empty can test, external rotation resistance), recognizing that pain itself significantly inhibits strength measurements and may not reflect true structural integrity 3
• Assess for impingement signs, though be aware that physical examination tests for shoulder impingement have insufficient evidence to reliably diagnose specific pathology 4, 5
• Evaluate for shoulder instability, as this can mimic rotator cuff pathology in younger patients 2

Critical Pitfall

Approximately 10% of rotator cuff tears are asymptomatic, so imaging findings must correlate with clinical presentation—do not treat images alone 2

Imaging Algorithm

Step 1: Plain Radiographs (Always First)

• Obtain at minimum three views: anteroposterior (AP), Grashey projection (30° posterior oblique), and either axillary lateral or scapular Y view 1
• Add suprascapular outlet view (Rockwood view) if impingement is suspected to evaluate anterior acromion morphology 2
• Purpose: Exclude fracture, dislocation, and assess bony alignment—these are the primary concerns requiring immediate management 1

Step 2: Advanced Imaging When Radiographs Are Normal

For Suspected Rotator Cuff Tear (Most Common in Weightlifting Injury)

• MRI without contrast is usually appropriate for evaluating rotator cuff pathology, providing high sensitivity and specificity for full-thickness tears 2, 6
• Ultrasound is equivalent to MRI for full-thickness tears if local expertise is available, with the advantage of being cost-effective and immediately available 6
• However, ultrasound is inferior to MRI for detecting partial-thickness tears (especially articular-sided) and has variable interobserver agreement 6
• Ultrasound cannot assess labral pathology, glenohumeral instability, or capsular injuries 6

For Patients Under 35 Years with Suspected Labral Tear or Instability

• MR arthrography is usually appropriate (rating 9) for suspected labral tears with or without instability 1
• MRI without contrast is also appropriate (rating 7) with optimized imaging equipment 1
• MR arthrography is particularly valuable for distinguishing partial from full-thickness tears and evaluating the undersurface of the rotator cuff 2

Management Approach

Conservative Management (First-Line)

• Most soft-tissue injuries including rotator cuff tears can undergo conservative management before considering surgery 1
• Conservative treatment includes: rest, ice, NSAIDs, and physical therapy 7
• Subacromial injection with local anesthetic can provide both diagnostic and therapeutic benefit, with studies showing dramatic improvements in strength (48% increase in peak torque for abduction) and pain relief in 86% of patients 3

When to Consider Surgical Referral

• Unstable or significantly displaced fractures require acute surgical management 1
• Persistent symptoms despite 6-12 weeks of conservative management warrant surgical consultation 7
• Complete rotator cuff tears in young, active patients may benefit from earlier surgical intervention to prevent tear progression

Key Clinical Pitfalls to Avoid

• Do not rely solely on physical examination tests to diagnose specific rotator cuff pathology—the evidence for their diagnostic accuracy is insufficient 4, 5
• Do not order MRI before plain radiographs—fractures and dislocations must be excluded first 1
• Do not assume ultrasound can replace MRI unless you have confirmed local expertise and are only evaluating for full-thickness rotator cuff tears 6
• Do not interpret pain-limited strength testing as definitive evidence of rotator cuff tear—pain itself dramatically reduces strength measurements 3
• Do not treat asymptomatic imaging findings—correlation with clinical presentation is essential 2