One-liner#
Adult/geriatric approach to atraumatic vs traumatic shoulder pain: triage urgent injury/infection, identify common patterns (rotator cuff, adhesive capsulitis, OA, AC joint), and set an outpatient-first plan.
Quick nav#
- Red flags / send to ED
- Key history
- Focused exam
- Differential (quick pattern recognition)
- Workup
- Initial management
- Management by diagnosis
- Follow-up
- Patient instructions
Red flags / send to ED#
- Trauma with deformity, suspected dislocation, or inability to move the arm due to severe pain
- Neurovascular compromise: new numbness/weakness in the hand/arm, cool/pale hand, diminished pulses
- Suspected septic joint: fever/systemic illness plus hot/swollen shoulder with severe pain on any motion
- Concern for referred high-risk pain (rare but important): shoulder/arm pain with chest pressure, dyspnea, diaphoresis, or syncope
Key history#
- Trauma vs atraumatic; “pop” sensation; immediate vs delayed pain/swelling
- Location: lateral shoulder (often rotator cuff), top of shoulder (AC), deep joint/groin-like (GH), scapular/neck
- Function: overhead reach, dressing/hand-behind-back, sleeping on that side, lifting
- Stiffness vs weakness: “can’t move it” (stiff) vs “can’t lift it” (weak)
- Night pain; mechanical symptoms (clicking, catching); instability episodes
- Prior dislocation, surgery, injection; diabetes/thyroid disease (adhesive capsulitis risk)
- Systemic symptoms (fever) or risk factors for infection
Focused exam#
- Inspect for asymmetry, swelling, ecchymosis; palpate AC joint and bicipital groove
- Active vs passive ROM: loss of both suggests adhesive capsulitis/OA; active-only loss suggests rotator cuff weakness/pain inhibition
- Strength: supraspinatus (empty can), external rotation, internal rotation; compare sides
- Provocative maneuvers (as needed): Hawkins/Neer (impingement), cross-body adduction (AC), Speed’s (biceps), apprehension/relocation (instability)
- Quick neck screen if radicular features (Spurling, neuro exam)
Differential (quick pattern recognition)#
Common/likely (outpatient)#
| Diagnosis | Keywords patients use | Key clues | Focused exam clues | Initial next step |
|---|---|---|---|---|
| Rotator cuff tendinopathy / subacromial pain | “Pain reaching up,” “hurts at night,” “aches on the outside” | Atraumatic, worse overhead; may wake from sleep | Painful arc; +Hawkins/Neer; strength mostly preserved | PT/home exercises, activity modification, analgesics; consider injection if persistent |
| Rotator cuff tear (esp. full-thickness) | “Can’t lift,” “weak,” “pop” | Trauma or acute worsening; true weakness | Weak external rotation/abduction; lag signs | Early imaging/referral if acute traumatic weakness |
| Adhesive capsulitis | “Frozen,” “stiff,” “can’t reach behind my back” | Gradual onset; diabetes/thyroid | Marked loss of active and passive ROM (esp. external rotation) | PT focused on mobility; consider injection; prolonged course |
| AC joint sprain/OA | “Top of shoulder,” “hurts crossing my arm” | Pain localized to AC; sometimes after fall | Tender AC; +cross-body adduction | Activity modification, topicals, PT; consider injection |
| Glenohumeral OA | “Deep ache,” “grinding,” stiffness | Older; gradual; limited ROM | Crepitus; decreased ROM | X-ray if it changes management; PT, analgesics; consider injection/referral |
| Cervical radiculopathy referred to shoulder | “Burning/shooting to arm,” numbness | Neck pain + arm paresthesias | +Spurling; neuro changes | Treat radiculopathy pattern; consider imaging if deficits |
Can’t-miss / urgent#
| Diagnosis | Keywords patients use | Key clues | Focused exam clues | Initial next step |
|---|---|---|---|---|
| Dislocation | “Popped out,” obvious deformity | Trauma; inability to move | Squared-off shoulder; limited ROM | ED/urgent reduction; post-reduction neurovascular exam |
| Fracture (prox humerus/clavicle) | “Severe after fall,” bruising | Trauma; focal bony pain | Point tenderness, swelling | Urgent imaging and immobilization |
| Septic arthritis | “Hot,” “throbbing,” feels sick | Fever/risk factors; severe pain with any motion | Warmth, effusion; pain with passive ROM | ED now; labs/aspiration/IV antibiotics |
Workup#
- No imaging for classic atraumatic rotator cuff tendinopathy without red flags.
- X-ray: trauma; suspected fracture/dislocation; suspected OA; persistent symptoms not improving with conservative care (typical: shoulder 2–3 views per local protocol).
- Ultrasound/MRI: suspected full-thickness tear with true weakness (esp. traumatic); pre-op planning; atypical/persistent cases.
- Labs: CBC, ESR/CRP only when infection/inflammatory arthritis is suspected.
Initial management#
- Activity modification (avoid painful overhead loading initially) while maintaining gentle ROM.
- Symptom relief: heat/ice, topical/oral analgesics as appropriate—see medication tables below.
- Start home exercise program and/or refer to PT early for function-limiting pain.
- Consider steroid injection pathway (subacromial, GH, or AC depending on pattern) when pain blocks rehab and conservative measures have failed.
Analgesic options for shoulder pain#
| Drug | Dose | Contraindications | Monitoring | Cost | Notes |
|---|---|---|---|---|---|
| Acetaminophen | 650–1000 mg q6–8h; max 3 g/day | Severe hepatic impairment | LFTs if prolonged use | $ | Safe first-line; limited efficacy alone |
| Ibuprofen | 400–600 mg q6–8h with food; max 2400 mg/day | CKD, GI bleed, HF, anticoagulation | Cr, BP if prolonged | $ | Effective for inflammatory component |
| Naproxen | 250–500 mg q12h; max 1000 mg/day | Same as ibuprofen | Same as ibuprofen | $ | Convenient BID dosing |
| Diclofenac gel 1% | Apply 4 g to shoulder QID | Avoid on broken skin | Minimal systemic absorption | $$ | Good for localized pain; lower systemic risk |
| Meloxicam | 7.5–15 mg daily | Same as ibuprofen | Same as ibuprofen | $ | Once-daily; COX-2 preferential |
Shoulder injection options (verify local protocol)#
| Injection site | Agent/Dose | Indications | Contraindications | Notes |
|---|---|---|---|---|
| Subacromial | Triamcinolone 40 mg + 3–5 mL lidocaine | Rotator cuff tendinopathy/impingement not responding to PT | Infection, overlying cellulitis | Posterior or lateral approach; provides 4–12 weeks relief |
| Glenohumeral (intra-articular) | Triamcinolone 40 mg + 3–5 mL lidocaine | Adhesive capsulitis, GH OA | Infection, overlying cellulitis | Often done with ultrasound guidance; consider early for adhesive capsulitis |
| AC joint | Triamcinolone 10–20 mg + 1 mL lidocaine | AC joint OA/sprain not responding to conservative care | Infection, overlying cellulitis | Small joint; use smaller volume |
When NOT to inject:
- Suspected septic joint (aspirate first)
- Full-thickness rotator cuff tear with significant weakness (injection may delay needed surgery)
- More than 3 injections per site per year
- Uncontrolled diabetes without glucose monitoring plan
Management by diagnosis#
Rotator cuff tendinopathy / subacromial pain#
- Education: common overuse pattern; strength and scapular control usually improve symptoms over weeks.
- Treatment:
- PT/home program (rotator cuff + scapular stabilizers) with graded return to overhead activity.
- Analgesics/topicals as appropriate.
- Consider subacromial injection when pain prevents rehab and diagnosis is consistent (verify local protocol).
- Follow-up: 4–6 weeks; sooner if true weakness develops.
Adhesive capsulitis#
- Education: prolonged course (months); focus is restoring motion and function, not “resting it.”
- Treatment:
- PT emphasizing capsular stretching and home ROM (prioritize external rotation and abduction).
- Consider intra-articular steroid injection early if pain-limited and ROM is significantly restricted (verify local protocol).
- Address contributory factors (diabetes/thyroid disease) in parallel.
- Follow-up: 4–6 weeks; consider referral if major functional limitation persists.
Suspected full-thickness rotator cuff tear (weakness)#
- Education: early assessment matters most when weakness is traumatic/acute.
- Treatment: protect from heavy lifting; early imaging and ortho/sports referral when indicated (especially acute traumatic weakness).
- Follow-up: within 1–2 weeks if weakness is present.
AC joint pain (sprain/OA)#
- Education: often improves with activity modification; cross-body loading can flare it.
- Treatment: topicals, PT (posture/scapular mechanics), brief avoidance of provoking movements; consider injection.
- Follow-up: 4–6 weeks if persistent.
Follow-up#
- Reassess in 2–6 weeks depending on severity and functional limitation.
- Return sooner for new deformity after trauma, new numbness/weakness, fever/hot swollen joint, or rapidly worsening pain.
- If not improving after 4–6 weeks of appropriate rehab, reconsider diagnosis (neck referral, tear, OA) and escalate (x-ray/US/MRI as indicated, injection pathway, or referral).
Patient instructions#
- Keep the shoulder gently moving daily (within comfort); avoid prolonged sling use unless directed.
- Avoid heavy overhead lifting until pain is improving; start with pain-free range and light resistance.
- Use ice/heat and over-the-counter pain options if safe for you.
- Seek urgent care for fever with a hot/swollen shoulder, sudden deformity after injury, or new weakness/numbness in the arm/hand.
Smartphrase snippets#
Rotator cuff tendinopathy:
Shoulder pain consistent with rotator cuff/subacromial pain; no red flags; neurovascularly intact. Discussed activity modification, PT/home program, analgesic options, and return precautions.
Adhesive capsulitis:
Shoulder pain with marked loss of active and passive ROM consistent with adhesive capsulitis. Plan: PT for capsular stretching and ROM, consider intra-articular injection if pain-limited. Discussed prolonged course (months) and importance of daily ROM exercises. Return precautions reviewed.
AC joint pain:
Shoulder pain localized to AC joint; tender over AC with positive cross-body adduction. Plan: activity modification (avoid cross-body loading), topical NSAID, PT for scapular mechanics. Will consider injection if persistent. Return precautions reviewed.
Suspected rotator cuff tear:
Shoulder pain with [traumatic/atraumatic] onset and true weakness on exam. Concern for rotator cuff tear. Plan: imaging [x-ray/ultrasound/MRI] and ortho referral. Avoid heavy lifting pending evaluation. Return precautions reviewed.
Related pages#
Complaint pages#
- Neck pain — cervical radiculopathy that may refer to shoulder
- Elbow pain — upper extremity evaluation
- Hand numbness — if neurologic symptoms present
Problem pages#
- Osteoarthritis — glenohumeral and AC joint OA management
Coding/billing notes (optional)#
- Document trauma mechanism (if present), ROM (active vs passive), and strength testing to support imaging/referral decisions.