What is the appropriate evaluation and management for a patient presenting with shoulder pain?

Evaluation and Management of Shoulder Pain

Initial Diagnostic Framework: Age-Specific Approach

For patients over 35-40 years, focus your evaluation on rotator cuff disease, degenerative changes, and impingement syndrome; for patients under 35-40 years, prioritize assessment of instability, labral tears, and sports-related injuries. 1

Essential History Components

Document the exact mechanism of injury including how any fall or trauma occurred, height of fall, landing position, and whether injury was work-related 1. Distinguish between traumatic (specific injury event) versus atraumatic presentations 1.

Classify symptom duration as acute (<2 weeks) or chronic (>6 months), as this fundamentally alters your diagnostic approach and management strategy 1.

Pain location provides critical diagnostic clues:

• Anterior shoulder → rotator cuff or biceps pathology 1, 2
• Superior shoulder → acromioclavicular joint disease 1, 2
• Scapular region → referred pain from cervical spine or rotator cuff 1

Identify aggravating factors such as overhead activities (suggests impingement), cross-body adduction (AC joint), or pain with arm behind back (subscapularis/posterior cuff) 1.

Screen for instability symptoms including history of dislocation, subluxation, or sensation of shoulder "giving way," particularly in patients under 40 years 1.

Red flags requiring immediate attention:

• Neurological symptoms (numbness, tingling, weakness, radiation down arm) suggesting cervical radiculopathy 1
• Systemic symptoms (fever, chills, constitutional symptoms) indicating possible septic arthritis 1
• Absent radial or ulnar pulses after trauma requiring immediate vascular imaging 1

Physical Examination Sequence

Position the patient sitting with 90° elbow flexion and hand supinated on the thigh for standardized assessment 3.

Inspect for muscle atrophy in the supraspinatus and infraspinatus fossae, which indicates chronic rotator cuff pathology 3.

Assess both active and passive range of motion:

• Forward flexion (normal 0-180°) 3
• External rotation (normal 0-90°) 3
• Internal rotation (ability to reach up the back) 3
• Key distinction: Limited passive motion suggests adhesive capsulitis; preserved passive with painful/weak active motion indicates rotator cuff pathology 1

Perform targeted provocative tests based on age:

For patients ≥35 years (rotator cuff focus):

• Empty can test (Jobe's test) for supraspinatus 3
• External rotation strength testing for infraspinatus/teres minor 3
• Lift-off test or belly press test for subscapularis 3
• Hawkins' test (92% sensitive) and Neer's test (88% sensitive) for impingement 1, 2

For patients <35 years (instability focus):

• Apprehension and relocation tests for anterior instability 1
• Posterior stress tests for posterior instability 1

Evaluate scapular position and movement for winging or dyskinesia, as scapular dysfunction contributes significantly to rotator cuff injury 1, 3.

Palpate systematically:

• Acromioclavicular joint 3
• Bicipital groove 3
• Proximal humerus 3
• Areas of swelling, warmth, or crepitus 3

Imaging Strategy: Algorithmic Approach

Step 1: Obtain plain radiographs first for ALL patients with shoulder pain using at least three views: anteroposterior in internal rotation, anteroposterior in external rotation, plus axillary or scapular-Y view 1, 3, 2. The axillary or scapular-Y view is essential because standard AP views alone miss up to 50% of dislocations 1.

Step 2: Advanced imaging based on clinical findings:

For patients ≥35 years with suspected rotator cuff pathology after normal/noncontributory radiographs:

• MRI without contrast is the preferred modality 1, 3, 2
• Musculoskeletal ultrasound is equivalent when performed by experienced operators (85% sensitivity, 90% specificity) and allows dynamic assessment 1, 3

For patients <35 years with suspected instability or labral pathology:

• MR arthrography is the gold standard, providing superior visualization of capsulolabral structures compared to standard MRI 1, 3

For fracture characterization:

• CT without contrast is superior for delineating fracture patterns and detecting subtle nondisplaced fractures 3, 2

Critical pitfall: Do not order MRI at initial evaluation when clinical findings clearly establish subacromial impingement diagnosis; MRI is only appropriate if symptoms persist after 3-6 months of conservative therapy or if full-thickness tear is suspected 1.

Conservative Management: Structured Protocol

Phase 1: Complete rest from aggravating activities until asymptomatic 1, 2. This is non-negotiable for rotator cuff tendinopathy.

Phase 2: Restore range of motion through gentle stretching and mobilization, focusing specifically on external rotation and abduction to prevent frozen shoulder 1, 2. Critical warning: Avoid overhead pulley exercises, which encourage uncontrolled abduction and worsen rotator cuff pathology 1, 2.

Phase 3: Strengthening program initiated only after achieving pain-free motion 1, 2:

• Rotator cuff strengthening with emphasis on eccentric exercises 1
• Scapular stabilizer strengthening 1, 2
• Progress through functional, individualized program over 1-3 months 1, 2

Adjunctive modalities:

• Ice, heat, and soft tissue massage 1, 2
• NSAIDs for acute pain management 1
• Subacromial corticosteroid injection (triamcinolone) for more severe cases not responding to initial measures within 4-6 weeks 1, 2

Evidence-based expectation: Approximately 80% of patients with subacromial impingement achieve full recovery within 3-6 months with supervised physical therapy; only 9% ultimately require surgical referral 1.

Specific Diagnoses and Management

Rotator Cuff Tendinopathy/Tear (Age ≥35 years)

Clinical presentation: Pain with overhead activities, weakness during pushup movements, positive empty can test, positive external rotation weakness, positive Hawkins'/Neer's tests 1, 2.

Management: Follow the three-phase protocol above. Return to activities only after completing 1-3 months of progressive rehabilitation without symptoms 1, 2.

Adhesive Capsulitis (Frozen Shoulder)

Clinical presentation: Diffuse shoulder pain with restricted passive range of motion, particularly external rotation and abduction 1, 4. Associated with diabetes and thyroid disorders 4.

Management: Aggressive stretching and mobilization focusing on external rotation and abduction 1. Consider serial casting for contractures interfering with function 1.

Shoulder Instability (Age <40 years)

Clinical presentation: History of dislocation or subluxation, sensation of shoulder "giving way," positive apprehension and relocation tests 1, 4.

Imaging: MR arthrography is mandatory for surgical planning 1, 3.

Acromioclavicular Joint Pathology

Clinical presentation: Superior shoulder pain, AC joint tenderness, painful cross-body adduction test 4.

Mandatory Specialist Referral Criteria

Immediate orthopedic referral required for:

• Unstable or significantly displaced fractures 1, 2
• Suspected massive rotator cuff tears requiring expedited repair 2
• Progressive neurological deficits 2
• Absence of arterial pulses after trauma 1

Orthopedic referral after failed conservative management:

• Persistent symptoms despite 3-6 months of appropriate conservative therapy 1
• Progressive weakness despite treatment 2

Common Pitfalls to Avoid

Do not assume absence of trauma means absence of fracture in elderly patients, where osteoporotic fractures occur with minimal or unrecognized trauma 1.

Do not misinterpret shoulder instability pain as impingement, cervical disc disease, or AC joint pathology, as this leads to incorrect management 1.

Do not order MRI prematurely when clinical diagnosis of impingement is clear; reserve advanced imaging for failed conservative therapy or suspected complete tears 1.

Do not prescribe overhead pulley exercises in rehabilitation programs, as they exacerbate rotator cuff pathology 1, 2.