How should I evaluate and manage right shoulder pain in the absence of red‑flag features?

Evaluation and Management of Right Shoulder Pain Without Red Flags

Initial Imaging is Mandatory

Plain radiographs must be obtained first in all patients presenting with shoulder pain, using a minimum three-view series: anteroposterior (AP) in internal rotation, AP in external rotation, and either an axillary or scapular Y view 1. This is non-negotiable because AP views alone miss up to 50% of dislocations and many fractures 1, 2. The axillary or scapular Y view is essential to properly assess glenohumeral alignment and detect posterior dislocations, which are missed in over 60% of cases without orthogonal views 3.

Age-Specific Diagnostic Framework

Your diagnostic approach must be stratified by age because the underlying pathology differs dramatically:

For patients ≥35-40 years old:

• Focus on rotator cuff disease, impingement syndrome, and degenerative changes as the primary pathology 1. Rotator cuff tendinopathy or tears are the most common cause in this age group 1, 4.
• Pain with overhead activities, weakness on empty can test, positive external rotation weakness, and positive impingement signs (Hawkins test 92% sensitive, Neer test 88% sensitive) strongly suggest rotator cuff pathology 1.
• Full-thickness rotator cuff tears occur predominantly in patients over 35 years and may show muscle atrophy and fatty infiltration on examination 1.

For patients <35-40 years old:

• Prioritize assessment for shoulder instability, labral tears, and sports-related injuries 1. Instability is the predominant pathology in younger patients 5, 1.
• Perform comprehensive instability testing including apprehension and relocation tests 1.
• Ask specifically about episodes of shoulder "giving way," subluxation, or frank dislocation 1.

Critical History Elements

Document these specific details:

• Pain location precisely: Anterior shoulder suggests rotator cuff or biceps pathology; superior shoulder indicates acromioclavicular joint disease; scapular region may indicate referred cervical spine pain 1.
• Mechanism and timing: Distinguish traumatic (specific injury event) from atraumatic onset, and classify as acute (<2 weeks) versus chronic (>6 months) 1.
• Functional limitations: Pain with overhead activities, cross-body adduction, or arm-behind-back movements (internal rotation) help localize the pathology 1.
• Previous shoulder history: Prior dislocations, fractures, or rotator cuff repairs significantly alter your differential 1.

Physical Examination Priorities

Perform these specific maneuvers based on age and presentation:

• Hawkins and Neer impingement tests for suspected rotator cuff tendinopathy (high sensitivity 92% and 88% respectively) 1.
• Empty can test and external rotation strength testing to assess rotator cuff integrity 1.
• Assess passive range of motion: Limited passive motion suggests adhesive capsulitis, while preserved passive motion with painful/weak active motion indicates rotator cuff pathology 1.
• Cross-body adduction test for acromioclavicular joint pathology 4.
• Apprehension and relocation tests in patients <40 years to evaluate for instability 1, 4.

Advanced Imaging Algorithm

After obtaining plain radiographs, proceed based on clinical findings:

If radiographs are normal and rotator cuff pathology is suspected (age >35 years, positive impingement signs):

• Order MRI without contrast OR high-quality ultrasound 1. Both modalities have equivalent sensitivity (85%) and specificity (90%) for detecting full-thickness rotator cuff tears when ultrasound is performed by experienced operators 1.
• MRI is preferred if local ultrasound expertise is limited or if you need to assess labral pathology, bone marrow edema, or muscle atrophy 5, 1.
• Do NOT order MRI initially if clinical findings clearly establish subacromial impingement syndrome—proceed directly to physical therapy 1.

If instability or labral pathology is suspected (age <35 years, history of dislocation):

• Order MR arthrography, not standard MRI 5, 1. MR arthrography is superior to non-contrast MRI for detecting labral tears, capsulolabral injuries, and partial-thickness rotator cuff tears 5, 1.

If acute trauma with normal radiographs but persistent pain:

• Order MRI without contrast 1. In acute trauma, joint effusion naturally provides contrast, making MR arthrography unnecessary 5, 1.
• MRI detects rotator cuff tears, labral injuries, bone marrow contusion, and capsular tears that are the most common causes of post-traumatic pain with normal radiographs 5, 1.

Initial Management Strategy

For rotator cuff tendinopathy/impingement (most common in patients >35 years):

Refer directly to physical therapy as first-line treatment 1. Evidence shows 80% of patients achieve full recovery within 3-6 months with supervised physical therapy 1.

The rehabilitation protocol must include:

• Complete rest from aggravating activities until pain-free 1.
• Stretching and mobilization to improve range of motion, especially external rotation and abduction 1.
• Eccentric strengthening exercises once pain-free motion is achieved 1.
• Scapular stabilizer strengthening to address scapular dyskinesis 1.

Avoid overhead pulley exercises—these encourage uncontrolled abduction and worsen rotator cuff pathology 1.

Adjunctive pain management:

• NSAIDs for acute pain control 1.
• Subacromial corticosteroid injection (triamcinolone) for more severe cases 1.

When to order MRI in rotator cuff cases:

MRI becomes appropriate only if: (1) symptoms persist despite 3-6 months of adequate physical therapy, (2) there is clinical suspicion for full-thickness tear (marked strength loss), or (3) imaging is needed for surgical planning 1.

For adhesive capsulitis:

• Aggressive stretching and mobilization focusing on external rotation and abduction 1.
• Avoid overhead pulley exercises 1.
• Consider serial casting for severe contractures 1.

Common Pitfalls to Avoid

• Never rely on AP radiographs alone—you will miss dislocations and many fractures 1, 3, 2.
• Do not assume absence of trauma means absence of fracture in elderly patients, where osteoporotic fractures occur with minimal trauma 1.
• Do not misinterpret shoulder instability pain as impingement or cervical disc disease—this leads to incorrect management 1.
• Do not order MRI before attempting 3-6 months of physical therapy for clear-cut impingement syndrome 1.
• Do not order standard MRI for suspected instability in young patients—MR arthrography is required 5, 1.

Surgical Referral Timing

Orthopedic referral is appropriate when:

• Radiographs show displaced fracture requiring operative fixation 1.
• Full-thickness rotator cuff tear is confirmed on imaging in a surgical candidate 5.
• Symptoms persist after 3-6 months of adequate conservative therapy 1.
• Recurrent instability episodes occur despite rehabilitation 1.

Only approximately 9% of patients with subacromial impingement ultimately require surgical referral after failed conservative management 1.