What is the likely diagnosis for an elderly man with intermittent right anterior shoulder pain and soreness when lying on the affected side, following band exercises to strengthen the rhomboids and improve posture?

Likely Diagnosis: Rotator Cuff Tendinopathy or Subacromial Bursitis

The most likely diagnosis in this elderly man with anterior shoulder pain following resistance band exercises is rotator cuff tendinopathy (tendinosis) with possible subacromial bursitis, given the mechanism of injury, age, location of pain, and aggravation with lying on the affected side. 1

Clinical Reasoning

Why This Diagnosis Fits

• Age factor: In elderly patients, shoulder pain is predominantly related to rotator cuff disease rather than instability, which is more common in younger patients (<35 years) 1

• Mechanism of injury: Band exercises performed in front of the torso to strengthen rhomboids involve shoulder protraction and internal rotation movements that can stress the rotator cuff tendons, particularly the supraspinatus and subscapularis 2

• Anterior shoulder pain: While rotator cuff pathology classically presents with lateral shoulder pain, anterior shoulder pain can occur with subscapularis tendinopathy or long head of biceps tendinosis, both of which are common in elderly patients 2

• Pain with lying on the shoulder: This is a classic sign of subacromial bursitis or rotator cuff tendinopathy, as compression of the inflamed bursa or irritated tendons against the acromion reproduces symptoms 2, 3

• Intermittent nature: Early-stage rotator cuff tendinopathy typically presents with intermittent pain rather than constant pain, distinguishing it from more severe pathology like full-thickness tears 1, 4

Differential Considerations

The differential diagnosis should include:

• Subacromial/subdeltoid bursitis: Often coexists with rotator cuff tendinopathy and presents with similar symptoms 2, 3

• Long head of biceps tendinopathy: Causes anterior shoulder pain and is commonly associated with rotator cuff disease 1

• Calcific tendinosis: Can present acutely with anterior shoulder pain in this age group, though typically more severe 5

• Acromioclavicular joint osteoarthritis: Less likely given the anterior location and mechanism, but should be considered 2

Diagnostic Approach

Initial Imaging

• Start with plain radiographs: Obtain anteroposterior (AP) views in internal and external rotation to evaluate for calcific tendinosis, acromioclavicular joint arthritis, and bony abnormalities 1

• If radiographs are noncontributory and clinical suspicion remains high: Proceed to advanced imaging 1

Advanced Imaging (When Indicated)

MRI without contrast and ultrasound are equally appropriate (rating 9/9) for evaluating suspected rotator cuff disease and bursitis in elderly patients 1

• MRI advantages: Better visualization of deep structures, marrow abnormalities, and full characterization of rotator cuff tears (partial vs. full-thickness) 1

• Ultrasound advantages: Can evaluate the acromioclavicular joint, rotator cuff tendons, long head of biceps tendon, and subacromial bursa; allows for dynamic assessment; can guide therapeutic injections if needed 1, 2

• Choice depends on local expertise: Both modalities are equivalent when performed by experienced practitioners 1

Management Recommendations

Conservative Treatment (First-Line)

• Gentle stretching and mobilization: Gradually increase active range of motion, particularly external rotation and abduction, while restoring alignment and strengthening weak muscles in the shoulder girdle 1

• Analgesics: Acetaminophen or ibuprofen for pain relief if no contraindications 1

• Activity modification: Avoid overhead activities and positions that reproduce pain initially 3

• Physical therapy: Focus on scapular stabilization and rotator cuff strengthening once acute pain subsides 1, 3

When to Consider Injections

• Subacromial corticosteroid injection: Appropriate when pain is thought to be related to subacromial bursa inflammation or rotator cuff tendinopathy, ideally performed under ultrasound guidance 1, 2

• Timing: Consider if conservative measures fail after 4-6 weeks 2, 3

Critical Pitfalls to Avoid

• Do not overlook rotator cuff tears in elderly patients: Older patients with shoulder pain following trauma or overuse have a significantly higher likelihood of rotator cuff tears compared to younger patients 6, 7

• Avoid aggressive passive range-of-motion exercises initially: Improper aggressive stretching of the complex shoulder joint can cause more harm than good, particularly if there is an underlying partial-thickness tear 1

• Do not ignore persistent or worsening symptoms: If symptoms do not improve with conservative treatment within 6-8 weeks, advanced imaging is warranted to rule out partial or full-thickness rotator cuff tears 1, 3

• Consider multiple pathologies: Elderly patients often have coexisting conditions (rotator cuff tendinopathy, bursitis, biceps tendinosis, AC joint arthritis) that may require different treatment approaches 2

• Avoid overhead pulley exercises: These can exacerbate impingement and should be avoided in the acute phase 1