Lateral shoulder pain in a hospital cleaner: cuff-related pain or frozen shoulder?
Mr A is a 57-year-old right-handed hospital cleaner referred with a 5-month history of right lateral shoulder pain. Pain is 7/10 at end range, wakes him twice nightly and prevents him lying on the right side; he has stopped reaching the top shelf at work and has cut his shifts from 8 to 6 hours. Active elevation is 105 degrees with a painful arc between 70 and 110 degrees, passive elevation 140 degrees, passive external rotation at the side 30 degrees and painful, internal rotation to L5. Hawkins-Kennedy is positive; drop-arm and external rotation lag signs are negative; resisted external rotation is pain-free but resisted mid-range abduction is painful. Cervical screen is clear, with no paraesthesia, and there is no history of trauma, weight loss, night sweats or fever. Radiographs report only mild acromioclavicular osteoarthritis. A subacromial corticosteroid injection 8 weeks ago gave 3 weeks of relief.
1. State your working diagnosis and explain which examination findings support it and which argue against the alternatives. What does the radiograph change?
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Working diagnosis: rotator-cuff-related shoulder pain (subacromial pain syndrome) with a minor acromioclavicular contribution. Supporting it: painful arc 70-110 degrees, pain on resisted mid-range abduction, positive Hawkins-Kennedy, night pain and inability to lie on the side, and the 3 weeks of relief from injection. Against a full-thickness cuff tear: negative drop-arm, negative external rotation lag, and pain-free resisted external rotation - a significant tear would usually show weakness or a lag. Against frozen shoulder: passive external rotation of 30 degrees and passive elevation of 140 degrees are only mildly reduced; a true frozen shoulder at 5 months would show marked loss of passive external rotation (the most restricted direction), a hard capsular end-feel and loss of function in all directions. Against cervical referral: clear screen, no paraesthesia, pain localised and mechanical. The radiograph changes nothing: mild AC osteoarthritis is common and usually asymptomatic at his age, does not explain a painful arc, and does not alter the loading plan. Imaging at this stage would not change management and should not be presented to him as the cause. Document the diagnosis as a clinical syndrome, not as an imaging finding, and record the negative red-flag screen.
2. Design a 12-week progressive loading programme with specific exercises, dose and progression rules, given his overhead work demands.
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Principle: progressive loading of the cuff and scapular muscles within an acceptable pain envelope (pain no more than 3/10 during exercise and settling within 24 hours), no complete rest, plus work-specific conditioning for overhead cleaning.
Weeks 1-2 (3 supervised sessions plus short daily home sessions): pain-free isometric abduction and external rotation, 5 x 30-45 seconds at 30-50% effort; scapular retraction and serratus work (band rows, wall slides); thoracic extension mobility; pain-free active-assisted elevation. Weeks 3-6: banded external rotation 3 x 8-12 at RPE 5, side-lying external rotation, prone rows, active elevation to tolerance allowing pain up to 3/10. Weeks 7-12: heavier loading - dumbbell press to 90 degrees then overhead, eccentric lowering, and shelf-reach simulation with 2-4 kg at shoulder height, 3 x 8-12 twice weekly, plus a work circuit (6 x 30 m carries, 10 overhead placements to a shelf).
Progression rule: add load only if pain settles within 24 hours and active elevation is improving; if not, hold load and cut volume by 30%. Monitoring: pain diary, active elevation, and a function score (SPADI or DASH) at 4 and 8 weeks. Work advice: temporary modified duties and a step stool during weeks 1-4 rather than stopping work.
3. What are your criteria and timeframe for onward referral, and what will you document?
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Referral trigger: refer for specialist shoulder review at 6-8 weeks (not before, if he is adherent and improving) if there is no meaningful change - less than 30% pain reduction, less than 15 degrees gain in active elevation, or no functional improvement. Refer earlier if he develops new weakness, a positive lag sign, or a sudden loss of active elevation suggesting a cuff tear; if night and rest pain escalate despite load reduction; or if he has trauma with immediate loss of active elevation (same-day referral).
Route: musculoskeletal/orthopaedic shoulder clinic with a view to guided injection or further imaging, not imaging alone - imaging without a management question rarely helps.
Documentation: baseline active and passive ranges, resisted test results and lag signs, pain scores and function score; the working diagnosis as a clinical syndrome and why the radiograph does not explain it; exercise dose, progression and the pain-monitoring rule taught; his work demands, hours and modified duties agreed; adherence; the natural-history explanation given (typically 6-12 weeks of loading for meaningful change, longer for full recovery); the specific review date and the criteria that would trigger earlier referral. This trail protects both the patient and your registration if he later presents elsewhere.