Synopsis
Localise shoulder pain by active and passive movement, distinguish rotator-cuff-related pain from adhesive capsulitis and glenohumeral disease, recognise acute tears and referred emergencies, and deliver staged rehabilitation, injection or surgical referral appropriately.
- Compare active with passive range: painful or weak active movement with relatively preserved passive movement supports rotator-cuff-related pain, while global active and passive restriction suggests capsulitis or arthritis.
- Adhesive capsulitis classically causes disproportionate loss of passive external rotation, followed by abduction and internal rotation, with gradual painful onset.
- No single cuff manoeuvre is definitive; use pain location, strength after analgesia, range, trauma and combinations of resisted abduction, external rotation and lag signs.
- Do not request routine ultrasound or MRI at first presentation of atraumatic cuff pain; image when trauma, major weakness, stiffness, failed rehabilitation or surgery creates a specific question.
- Provide explanation, temporary load modification and progressive cuff, scapular and range exercise, normally over at least six to twelve weeks before judging conservative care unsuccessful.
- A targeted subacromial or glenohumeral corticosteroid injection can give short-term relief enabling exercise; exclude infection and avoid serial injections without durable gain.
- Refer an acute traumatic suspected full-thickness tear promptly; refer persistent disabling cuff disease or frozen shoulder after an adequate supported pathway.
- Shoulder pain may come from neck, heart, lung, diaphragm or malignancy; a normal shoulder examination or movement-independent pain should widen assessment.
Key red flags
Acute traumatic inability to raise the arm with true weakness, particularly in an older adult, can indicate a full-thickness cuff tear and needs expedited specialist imaging and referral.
Fever, marked warmth, rapid effusion, immunosuppression or severe pain through every passive movement raises septic arthritis and needs same-day hospital assessment.
A locked internally rotated arm after seizure or electrical injury suggests posterior dislocation even when an anteroposterior radiograph is inconclusive.
Progressive night pain, weight loss, a mass or previous cancer needs malignancy imaging; apical lung tumours can combine shoulder pain with hand weakness or Horner syndrome.
Shoulder discomfort with exertional chest pressure, breathlessness, diaphoresis, haemodynamic change or visceral symptoms requires urgent non-musculoskeletal assessment.
Investigation priorities
Localise glenohumeral, cuff, acromioclavicular, cervical or referred pain and identify trauma, infection or major weakness.
Management branches
Atraumatic or low-energy shoulder pain is present without deformity, systemic illness or neurovascular loss.
- Screen chest, lung, abdomen, neck, systemic symptoms and cancer risk, then compare active range, passive range, cuff strength, acromioclavicular tenderness and distal neurology.
- Classify a predominantly cuff-related, stiff glenohumeral, acromioclavicular, cervical or referred pattern without overclaiming a single special test.
- Use radiography for trauma, stiffness or atypical disease and reserve ultrasound or MRI for weakness, failed care or a specific specialist decision.
- Give return advice for fever, swelling, new weakness, deformity, chest symptoms or escalating unremitting pain.
Rotator-cuff-related pain is likely and no acute repairable tear or urgent lesion is suspected.
- Explain that tendon findings are common, then modify only provocative overhead or heavy load rather than resting the arm completely.
- Begin tolerable range, isometric or low-load cuff and scapular-control exercise, progressing resistance and functional reach over six to twelve weeks.
- Use topical or brief oral analgesia to enable sleep and exercise; consider one accurately placed subacromial steroid injection after infection exclusion.