Lateral shoulder pain in a patient with type 2 diabetes
Ahmed, a 54-year-old warehouse supervisor, presents with a 10-week history of right lateral shoulder pain. He reports no trauma. Pain is 6/10 at rest and 8/10 with overhead reaching; night pain wakes him two to three times per week. Active range of motion: flexion 110°, abduction 85° with a painful arc from 70° to 100°, external rotation 30°, internal rotation to the buttock. Neer and Hawkins-Kennedy tests are positive; the empty-can test is painful but not weak. Cervical screening is negative. His HbA1c is 8.9%, BMI 31, and he works 10-hour shifts. He requests ultrasound and shockwave because a friend improved with them. He can attend only one session per week. He asks whether he needs an MRI and whether he should stop work.
1. Interpret the examination findings and give a working diagnosis with two alternative diagnoses. Explain how the diabetes and night pain influence your reasoning.
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Working diagnosis: rotator cuff-related shoulder pain (subacromial pain syndrome). The painful arc, positive Neer and Hawkins-Kennedy tests, and pain-limited range fit this pattern. Alternatives: (1) early adhesive capsulitis - diabetes is a risk factor, and external rotation is reduced, but the painful arc and impingement signs are more typical of subacromial pain; (2) calcific tendinopathy or partial-thickness cuff tear - possible, but the empty-can test is painful without weakness, making a large full-thickness tear less likely. Night pain and diabetes matter: diabetes is associated with stiffer shoulders and poorer tendon healing, so I would monitor range and educate about the longer course. The absence of trauma, marked weakness, sensory change, and a positive cervical screen makes radiculopathy and acute tear less likely. I would not label this 'impingement' as a structural diagnosis; manage it as a load-related shoulder problem.
2. Justify whether an MRI or orthopaedic referral is indicated now, and state what findings would change your decision.
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An MRI is not indicated now. There is no trauma, no pseudoparalysis, no progressive weakness, and symptoms are 10 weeks. Many asymptomatic people have cuff changes on MRI, so imaging is unlikely to change first-line management. I would refer for imaging or orthopaedic review if any of the following appear: acute traumatic onset with weakness, inability to actively elevate the arm, progressive weakness, a suspected full-thickness tear, failure to improve after 6–12 weeks of targeted rehabilitation, or red flags such as unexplained weight loss, fever, previous cancer, or unrelenting night pain. His night pain alone is common in cuff-related pain and does not mandate imaging. I would explain this and arrange review at 3 and 6 weeks.
3. Design a one-session-per-week management plan for the first 6 weeks, including self-management, load modification, and your response to his request for ultrasound and shockwave.
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Weeks 1–2: education about load management; avoid overhead lifting above shoulder height and repetitive reaching; use a step stool and take micro-breaks at work. Pain relief: relative rest, paracetamol/NSAIDs as advised by his GP, and sleep positioning. Home programme: pendular exercises, active-assisted flexion and external rotation, scapular retraction, and submaximal isometrics, 2–3 times daily, 5–10 repetitions. Weeks 3–6: progress to active range, then light resistance bands for external rotation and rows; add work-specific overhead reaching with a light load. One supervised session per week: reassess, correct technique, progress load. Ultrasound/shockwave: explain that evidence is limited and it is not first-line; shockwave may be considered for calcific tendinopathy, which is not established here. If he still wants it, discuss uncertainty and use only as an adjunct, not instead of exercise. Liaise with his GP about HbA1c, because glycaemic control affects shoulder outcomes.