What is the appropriate evaluation and management for a 66-year-old woman presenting with left shoulder pain?

Evaluation and Management of Left Shoulder Pain in a 66-Year-Old Woman

Begin with standard three-view shoulder radiographs (AP in internal and external rotation plus axillary or scapular-Y view) as your first imaging study, because this age group most commonly has rotator cuff disease that radiographs can help characterize through indirect signs like subacromial narrowing and greater tuberosity changes. 1

Initial Clinical Assessment

Key History Elements to Obtain

• Pain with overhead activities and weakness during pushup movements strongly suggest rotator cuff tendinopathy in patients over 35-40 years 2
• Anterior shoulder pain suggests rotator cuff or biceps pathology, while superior shoulder pain indicates acromioclavicular joint disease 2
• Morning stiffness lasting >1 hour, fever, weight loss, or fatigue in patients >50 years strongly suggests polymyalgia rheumatica or inflammatory arthritis 3
• Neck pain or radicular symptoms point toward cervical radiculopathy as the primary pain source 3

Physical Examination Priorities

• Perform the empty can test and external rotation weakness testing (96% sensitive for rotator cuff tears) 3
• Hawkins' test (92% sensitive) and Neer's test (88% sensitive) for impingement syndrome 2
• Positive Spurling's test or radicular pattern on cervical examination indicates cervical pathology referring pain to the shoulder 3

Imaging Algorithm

Step 1: Plain Radiographs (Always First)

Radiographs are the preferred initial diagnostic modality because they delineate shoulder malalignment and most shoulder fractures 1. The standard trauma series must include:

• AP views in internal and external rotation
• Axillary or scapular-Y view (vital for detecting dislocations that can be missed on AP views alone) 1

Step 2: Advanced Imaging (When Indicated)

Order MRI without contrast if radiographs are normal or indeterminate and rotator cuff integrity needs assessment, as this is the procedure of choice for patients ≥35 years where shoulder pain is predominantly related to rotator cuff disease 1, 4

Ultrasound is equivalent to MRI for rotator cuff evaluation when performed by experienced operators (85% sensitivity, 90% specificity) and is more practical for bilateral assessment 2, 3

CT without contrast is advantageous for identifying subtle nondisplaced fractures and characterizing complex fracture morphology when radiographs are indeterminate 1

Initial Conservative Management

First-Line Treatment (3-6 Months Required)

Conservative therapy should be the first-line approach, employing structured physical therapy programs that emphasize rotator cuff strengthening, range-of-motion, and scapular stabilization exercises 4

Specific interventions include:

• Complete rest from all aggravating activities until asymptomatic 2
• Ice, heat, and soft tissue massage as adjunctive modalities 2
• Gentle stretching and mobilization techniques focusing specifically on external rotation and abduction to prevent frozen shoulder development 2
• Avoid overhead pulley exercises as they encourage uncontrolled abduction and can worsen rotator cuff pathology 1, 2
• Activity modification and proper positioning to lessen mechanical stress on the subacromial space 4

Progression of Therapy

Begin rotator cuff and scapular stabilizer strengthening only after achieving pain-free motion, progressing through a functional, individualized program over 1-3 months 2

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 2

Arthroscopic subacromial decompression should be offered only after failure of adequate conservative therapy (≥3 months of structured treatment), as high-quality trials demonstrate outcomes comparable to exercise-based rehabilitation 4

Red Flags Requiring Immediate Specialist Referral

Refer immediately to an orthopedic specialist for:

• Presence of neurological deficits 4, 2
• Unstable or significantly displaced fractures 1, 4
• Suspected massive rotator cuff tears requiring expedited repair for optimal outcomes 1, 2
• Progressive weakness despite appropriate treatment 2

Any bilateral upper-extremity weakness, sensory change, or gait disturbance should trigger immediate referral to a spine specialist for possible cervical myelopathy 3

Critical Pitfalls to Avoid

• Do not order shoulder MRI before checking inflammatory markers if systemic symptoms are present, as this wastes resources and delays treatment of polymyalgia rheumatica requiring prompt corticosteroid therapy 3
• Missing cervical myelopathy: shoulder pain with subtle upper-extremity weakness may be the first sign of cervical cord compression requiring urgent neurosurgical evaluation 3
• Do not attribute all postoperative improvement solely to surgery; spontaneous recovery and concurrent non-surgical interventions may contribute to perceived benefits 4
• Aggressive passive range-of-motion exercises, when performed improperly, can cause additional harm to the shoulder joint 4

Timeline for Specialist Referral

Refer when ≥3 months of structured conservative therapy have failed and the patient continues to experience functional limitation 4

Symptoms that persist or worsen after 6-12 weeks of directed treatment should be referred to an orthopedic specialist 5