How should I evaluate and manage a 65-year-old male with posterior right shoulder pain?

Evaluation and Management of Posterior Right Shoulder Pain in a 65-Year-Old Male

Order plain radiographs immediately with three mandatory views: anteroposterior in internal rotation, anteroposterior in external rotation, and an axillary or scapular Y view—this is your first-line imaging regardless of suspected pathology. 1, 2, 3

Initial Imaging Protocol

• Obtain upright radiographs (not supine) because supine positioning significantly underrepresents shoulder malalignment and can miss critical pathology 1, 2, 3
• The axillary or scapular Y view is non-negotiable—AP views alone miss up to 50% of glenohumeral and acromioclavicular dislocations, even in non-traumatic presentations 1, 2, 3
• These three views will identify fractures (including osteoporotic fractures from minimal trauma), joint malalignment, calcific tendinitis, bone erosions, and acromioclavicular joint pathology 2, 3

Critical History Elements to Document

Determine if this is traumatic or atraumatic pain first—this single distinction drives your entire differential diagnosis and management pathway 1, 2:

If Traumatic (even minor trauma):

• Document exact mechanism: how any fall occurred, height, landing position, whether work-related 2
• Note time of injury and symptom evolution since onset 2
• Ask specifically about any sensation of shoulder "giving way" or instability during the event 2
• Remember: absence of recalled trauma does not exclude fracture in a 65-year-old—osteoporotic fractures occur with minimal or unrecognized trauma 2

If Atraumatic:

• At age 65, your primary differential is rotator cuff disease, degenerative changes, impingement syndrome, and glenohumeral osteoarthritis—not instability 2, 4
• Document pain location precisely: posterior shoulder pain specifically suggests rotator cuff pathology involving the infraspinatus/teres minor or referred pain from cervical spine 2
• Ask about pain with overhead activities, weakness during pushup movements, and pain during arm-behind-back movements (internal rotation/extension implicates subscapularis) 2

Red Flags to Screen:

• Fever, chills, or constitutional symptoms suggesting septic arthritis 2
• Neurological symptoms: numbness, tingling, weakness, or radiation down the arm suggesting cervical radiculopathy 2
• Absent radial or ulnar pulses (requires immediate vascular imaging) 2

Physical Examination Priorities

Focus your examination on rotator cuff pathology and degenerative disease—not instability testing—because this patient is over 40 years old 2, 4:

• Hawkins test (92% sensitive for impingement) and Neer test (88% sensitive) 2
• Empty can test for supraspinatus weakness 2
• External rotation strength testing against resistance 2
• Assess passive range of motion—if limited and painful, consider adhesive capsulitis; if preserved passive motion with painful/weak active motion, suspect rotator cuff tear 2
• Palpate the acromioclavicular joint and perform cross-body adduction test if superior shoulder pain is present 4
• Check radial and ulnar pulses 2

Imaging Decision Algorithm After Initial Radiographs

If radiographs show fracture or significant arthritis:

• Unstable or significantly displaced fractures require immediate orthopedic referral 2
• Stable fractures can be managed conservatively with delayed orthopedic consultation if non-operative treatment fails 2

If radiographs are noncontributory and clinical findings suggest rotator cuff pathology:

• Order MRI without contrast (rated 9/9 by ACR) for patients over 35 years with suspected rotator cuff tendinopathy or tears 1, 2
• Ultrasound is equivalent to MRI for rotator cuff evaluation if local expertise is available (85% sensitivity, 90% specificity), and allows dynamic assessment during movement 1, 2
• Do NOT order MRI initially if clinical findings clearly establish subacromial impingement—reserve MRI for patients who fail 3-6 months of conservative therapy or when full-thickness tear is suspected 2

If radiographs are noncontributory and you suspect labral pathology or instability (unlikely at age 65):

• MR arthrography is the gold standard (rated 9/9 by ACR) 1
• However, instability is predominantly a disease of patients under 40 years—reconsider your diagnosis in a 65-year-old 2, 4

Initial Management Based on Most Likely Diagnosis

For rotator cuff tendinopathy/impingement (most likely in this age group) 2, 4:

1. Complete rest from aggravating activities until asymptomatic 2
2. Refer to physical therapy immediately—evidence-based conservative care leads to full recovery in 80% of patients within 3-6 months 2
3. Physical therapy protocol should include:
   • Stretching and mobilization to improve range of motion, especially external rotation and abduction 2
   • Eccentric strengthening exercises once pain-free motion is achieved 2
   • Scapular stabilizer strengthening 2
   • Avoid overhead pulley exercises—these encourage uncontrolled abduction and worsen rotator cuff pathology 2
4. NSAIDs for acute pain management 2
5. Intra-articular corticosteroid injection (triamcinolone) for more severe cases 2
6. Orthopedic referral is premature before a well-managed 3-6 month trial of conservative therapy—only about 9% ultimately require surgery 2

Common Pitfalls to Avoid

• Do not rely on AP radiographs alone—you will miss posterior dislocations, AC joint separations, and subtle malalignment 1, 2, 3
• Do not assume absence of trauma means absence of fracture in elderly patients 2
• Do not order MRI before obtaining plain radiographs—radiographs are mandatory first-line imaging 1, 2, 3
• Do not perform instability testing as your primary examination focus in patients over 40 years—focus on rotator cuff and degenerative pathology instead 2, 4
• Do not refer to orthopedics before attempting 3-6 months of physical therapy unless fracture or complete tear is evident 2