Which findings really matter, who to inject, when to refer urgently and more…

Shoulder pain is a common musculoskeletal presentation in general practice—and one of the most nuanced to manage, says specialist orthopaedic shoulder surgeon Dr Sushil Pant, founder and medical director of the Sydney Shoulder Unit. Following these key principles can help you make diagnostic and treatment decisions that lead to better patient outcomes.

Tip 1: Physical examination findings that matter most

Along with loss of range—particularly in forward elevation, external rotation and internal rotation—weakness provides key clues about the likely problem, Dr Pant says.

“That often is the giveaway for any rotator cuff pathology. If we find weakness, we try and work out in which direction. So, we test the supraspinatus with the Jobe’s test and then external rotation for the posterior cuff and then the anterior cuff.”

The AC joint is very sensitive to direct palpation and can be a complex source of pain, he adds, noting the biceps tendon can also be tender. “Those are very common areas of pain we should look for.”

He also advises testing for a painful arc, which often indicates subacromial impingement.

Tip 2: A plain X‑ray is essential

“A lot is missed by not obtaining a plain X-ray at the start of a patient’s journey, particularly with any big issues,” Dr Pant says.

While ultrasound can be a useful first test, it will not detect glenohumeral arthritis, posterior dislocation, greater tuberosity fractures, glenoid fractures, AC joint pathology and bone lesions, he notes.

In post‑fall presentations, particularly with weakness or inability to move the arm, one critical X-ray finding is a greater tuberosity fracture—which can occur as the ball goes back into the socket following dislocation, he explains.

“And the greater tuberosity fracture in and of itself essentially renders that patient with a functional cuff tear—even if the ultrasound reports an intact cuff.”

These patients should be managed in an abduction (pillow) sling in neutral rotation, he advises. “The worst thing you can do is put them in internal rotation and strap their arm across their body, because that really puts a deforming force on that fragment to pull it more posterior.”

X-ray is also essential for excluding avascular necrosis (AVN), especially if you’re considering a cortisone injection, he stresses.

Tip 3: When to inject cortisone (and when not to)

Along with AVN, cortisone should be avoided in patients with symptomatic, repairable cuff tears. “If a cortisone injection is placed within a three-month window, I can’t offer surgery,” Dr Pant explains.

So, when is it appropriate?

Frozen shoulder is a leading indication, with early injection into the glenohumeral joint potentially transforming outcomes. “That’s where the pathology is, and that’s where we should be injecting it,” Dr Pant says.

“And we know that the earlier you inject cortisone, the lower the intensity of their pain and the shorter the duration of their symptoms.”

Night pain typically eases within a week or two afterwards, while range of movement improves more slowly. One injection is usually enough, but the occasional patient needs two, he explains.

In patients who do need a second injection, Dr Pant looks for other pain sources, such as the bursa, AC joint or biceps tendon—noting you can inject into these if needed.

Guided injection into the bursa may also be appropriate first-line treatment for patients with bursitis on ultrasound or MRI but no rotator cuff tears, or for those who are definitely not a surgical candidate, he adds.

Tip 4: When to refer urgently

Younger patients with acute cuff tears should be referred for MRI and surgical review without delay, Dr Pant stresses.

“There’s sometimes a narrow window to fix these tears. We know that the younger the patient is, the more traumatic the tear, the larger the tear at the time of the event, the more likely it is to progress,” he explains.

“The vector force is always pulling that tendon away from the bone. Over time, it will just pull away further and further, and it can become irreparable, particularly once there is fat infiltration and the tear has retracted to the glenoid margin.”

Older patients with small degenerative tears have a bigger window, he says.

“Those tears don’t progress that fast. In fact, if we MRI these patients when they have minimal symptoms and they’re not sure, I say to them, just go on with your therapy, get on with your life, and I’ll see you in a year or two, we’ll repeat a scan. If your symptoms change, come and see me earlier.”

That said, any suggestion of a subscapularis tear on imaging in patients up to about the age of 70 warrants urgent referral. These injuries are a “game changer”, Dr Pant says, likening them to “losing your thumb”.

“A subscapularis tear changes your shoulder function entirely. Often those patients have bicep dislocation as well. It’s a devastating injury.”

You should also refer anyone over 40 with an instability event and persistent weakness weeks later, he adds. “Those patients often will have quite a significant cuff injury, and that sort of tear progresses fast.”

Tip 5: Age predicts instability recurrence

“The number one predictor of recurrence of instability is the age of first dislocation,” Dr Pant says. “If you’re under 20, probably 25, at your first episode, you have over 80% chance of recurrence.”

Risk is also increased in patients who play overhead, contact or collision sports, compete at a high level, or have significant bony or labral injury on imaging.

Some younger patients with instability need surgery—but not all, Dr Pant says.

“A 20-year-old playing rugby with a bony Bankart and a Hill-Sachs lesion—that is going to dislocate. The question isn’t will this patient require surgery. It’s more when and what operation.”

Conversely, a 27-year-old recreational tennis player with a small labral tear may manage well with rehabilitation alone.

“They don’t always need surgery because they’re a little bit older. As we get older, we get a bit stiffer. If they have a second or third instability episode, that’s when you might refer.”

Tip 6: Frozen shoulder patients most likely to need surgery

Some patients have a subset of frozen shoulder that’s more aggressive, with significant range restriction and intense pain, Dr Pant notes.

The patients who may need surgery are those who’ve “run out of gas,” he says. They struggle to sleep, work, care for their families, manage their personal hygiene, and have plateaued or gone backwards despite treatment.

“Before I even examine their shoulder, I look at their face—they’re exhausted,” he says.

When he scopes these shoulders, they are “often red and dark, with very intensely inflamed tissue where the shoulder is really scarred and tight.”

Surgery can be life‑changing for this group when performed at the right time—which is when the patient asks for it because they’ve had enough, he says.

The procedure must deal with all the pathologies contributing to symptoms, including the biceps tendon, AC joint and subacromial space, he adds. “Otherwise, with just a capsular release, I find they don’t progress that well.”

Tip 7: Imaging should support clinical reasoning

Ultrasound is commonly used in general practice and Dr Pant considers this reasonable, but “it might be only correct 40–50% of the time.”

“It’s a mistake today for us just to rely on reports rather than history and examination,” he cautions.

For example, a small degenerative supraspinatus tear in an older patient with good range of motion may not be clinically relevant. “Not all rotator cuff tears are bad, and not all rotator cuff tears need surgery,” he says.

“In fact, sometimes doing a rotator cuff repair could be a detriment to that patient, because it may not be their symptom generator. They may have bicep tendonitis, or AC joint pain, or capsulitis, or shoulder arthritis, or cervical spine pain, or some other diagnosis.”

Tip 8: Consider functional age

Regardless of the patient’s chronological age, it’s crucial to consider their lifestyle—which dictates the level of shoulder function they need, Dr Pant stresses.

“Some patients, even in their 70s or 80s, are very active. They’re playing a lot of sport. They’re cycling. They’re golfing. They have certain demands on their body.”

Patients may be miserable if they can’t get back to activities that “give them a great deal of joy”, he says, and this guides treatment decisions.