Medial Shoulder Pain Worsening with Lifting
This presentation most likely represents rotator cuff-related shoulder pain (RCRSP), specifically involving the rotator cuff tendons (supraspinatus, subscapularis, or biceps) or subacromial bursa, and should be managed with immediate plain radiographs followed by graduated exercise therapy as first-line treatment. 1
Initial Diagnostic Approach
Start with plain radiographs including anteroposterior views in internal and external rotation plus either an axillary or scapular-Y view to rule out fracture, dislocation, or arthritis. 1 This imaging will identify structural abnormalities that require different management pathways. 1
Perform a focused physical examination looking for:
- Painful arc between 60-120° of abduction/flexion (classic for rotator cuff pathology) 1
- Rotator cuff strength testing in all planes 1
- Passive range of motion assessment 1
- Tenderness over biceps tendon and supraspinatus (medial shoulder pain often involves these structures) 2
- Positive Neer impingement sign (pain with passive abduction of internally rotated arm) 2
First-Line Management
Begin immediate gentle mobilization with passive and active-assisted range-of-motion exercises focusing on external rotation and abduction movements. 1 Early mobilization is mandatory to prevent adhesive capsulitis (frozen shoulder), particularly in women over 50 years. 1
Prescribe ibuprofen taken before bedtime rather than acetaminophen for rotator cuff-related pain and improving sleep quality. 1 However, counsel patients that NSAID therapy carries risks of worsening kidney function in those with renal disease, development or exacerbation of hypertension, heart failure, and gastrointestinal ulceration or bleeding. 1
Exercise Progression
Implement graduated exercise therapy as the primary treatment, as high-quality research demonstrates that well-constructed exercise approaches confer at least equivalent benefit to surgery for rotator cuff tendinopathy, partial thickness tears, and atraumatic full thickness tears. 3
Progress exercises gradually while restoring alignment and strengthening shoulder girdle muscles. 4, 5
Critical Pitfalls to Avoid
Never use overhead pulley exercises as they may worsen impingement and increase risk of shoulder pain. 1, 5
Avoid static positioning or strapping of the upper extremity, as evidence for preventing pain or loss of range of motion is not well established. 1
Do not delay mobilization as early movement is essential to prevent frozen shoulder. 1
Escalation if No Improvement
If no improvement after 3-4 weeks of conservative management, consider the following options:
- Ultrasound evaluation to detect soft tissue injuries 1, 4
- Subacromial corticosteroid injection for rotator cuff or bursa inflammation 1, 5
- MRI without contrast for detailed tissue assessment 1
- Specialist referral to orthopedics 1
Additional Considerations
Rotator cuff pathology is the leading cause of shoulder-related disability, affecting approximately 8% of American adults with chronic shoulder pain. 2 The prevalence increases with age, with 54% of asymptomatic patients aged 60 years or older having sustained rotator cuff tears. 2 Pain that worsens with lifting is characteristic of rotator cuff tendinopathy or subacromial impingement, as these structures are mechanically loaded during overhead or lifting activities. 3, 6
Medial shoulder pain specifically may involve the biceps tendon or subscapularis tendon, both of which are located more medially and are commonly injured in rotator cuff-related conditions. 2 About one third of patients have abnormal ultrasound findings including effusion in biceps tendon or subacromial bursa, and tendinopathy of biceps, supraspinatus, or subscapularis. 2