What is the appropriate management for a 50-year-old male with right shoulder pain exacerbated by movement for 1 month?

Management of Right Shoulder Pain in a 50-Year-Old Male

For a 50-year-old male with one month of movement-related shoulder pain, the most likely diagnosis is rotator cuff tendinopathy, and initial management should include complete rest from aggravating activities, NSAIDs for pain control, and a structured physical therapy program focusing on range of motion followed by progressive strengthening. 1

Initial Diagnostic Approach

History and Physical Examination Priorities

Document these specific pain characteristics:

• Exact location: anterior shoulder suggests rotator cuff or biceps pathology; superior shoulder indicates acromioclavicular joint disease 1
• Pain with overhead activities and weakness during pushup movements strongly suggests rotator cuff tendinopathy in patients over 35-40 years 1
• Pain during arm-behind-back movements (internal rotation and extension) specifically implicates subscapularis tendon pathology 1

Perform these specific physical examination maneuvers:

• Empty can test and external rotation weakness testing for rotator cuff pathology 1
• Hawkins' test (92% sensitive) and Neer's test (88% sensitive) for impingement syndrome 1
• Assess passive range of motion: preserved passive motion with painful/weak active abduction confirms rotator cuff pathology rather than adhesive capsulitis 1
• Evaluate scapular dyskinesis, as poor scapular coordination contributes significantly to rotator cuff injury 1

Imaging Strategy

Obtain plain radiographs first with at least three views: anteroposterior views in internal and external rotation, plus axillary or scapular Y view 1, 2

For persistent symptoms after initial treatment, order MRI without contrast as the preferred advanced imaging for rotator cuff disorders in patients over 35 years 1

Alternatively, musculoskeletal ultrasound is equivalent to MRI for rotator cuff evaluation when performed by experienced operators, with 85% sensitivity and 90% specificity, and allows dynamic assessment during arm movement 1

Initial Conservative Management

Phase 1: Pain Control and Rest (First 2-4 Weeks)

Complete rest from all aggravating activities until asymptomatic 1

Prescribe ibuprofen 400 mg every 4-6 hours as needed (maximum 3200 mg daily), taken with meals or milk to minimize gastrointestinal complaints 3

Apply ice, heat, and soft tissue massage as adjunctive modalities 1

Phase 2: Range of Motion Restoration (Weeks 2-6)

Initiate gentle stretching and mobilization techniques focusing specifically on external rotation and abduction to prevent frozen shoulder development 1

Avoid overhead pulley exercises as these encourage uncontrolled abduction and can worsen rotator cuff pathology 1, 2

Consider shoulder strapping as both preventive and therapeutic intervention, as lateral rotation is the factor most significantly related to onset of shoulder pain 1

Phase 3: Strengthening (Weeks 4-12)

Begin rotator cuff and scapular stabilizer strengthening only after achieving pain-free motion 1

Progress through a functional, progressive, and individualized program over 1-3 months without evidence of symptoms before returning to full activities 1

When Conservative Management Fails

Consider subacromial corticosteroid injection (triamcinolone) for more severe cases that do not respond to initial conservative measures within 4-6 weeks, as these have significant effects on pain 1

For pain thought to be related to spasticity or muscle tightness, botulinum toxin injections into subscapularis and pectoralis muscles can be used 4

Red Flags Requiring Specialist Referral

Refer immediately to orthopedic specialist for:

• Presence of neurological deficits 2
• Suspected massive rotator cuff tears requiring expedited repair for optimal outcomes 2
• Failure of conservative management after 3 months 5
• Progressive weakness despite appropriate treatment 1

Common Pitfalls to Avoid

Do not assume absence of trauma means absence of pathology in this age group, as rotator cuff tears can occur from repetitive eccentric stress without a specific traumatic event 1

Do not delay imaging if symptoms persist beyond 4-6 weeks of appropriate conservative management, as inadequate imaging can lead to missed diagnoses 6

Do not prescribe overhead pulley exercises, which are commonly recommended but actually worsen rotator cuff pathology by encouraging uncontrolled abduction 1, 2