Persistent Shoulder Pain and Weakness After a Fall

Learning objectives#

• Reassess shoulder trauma when pain persists or active function remains substantially impaired after initial radiographs.
• Distinguish glenohumeral motion loss from pain-limited or weakness-limited active elevation by comparing active and passive movement.
• Prioritize fracture, unreduced dislocation, neurovascular injury, acute rotator cuff tear, and referred emergencies before labeling symptoms as impingement or strain.
• Select radiography, ultrasound, MRI, CT, or electrodiagnostic testing according to the question each test can answer.
• Interpret a traumatic full-thickness tear in the context of age-related tendon change without overstating imaging causality.
• Compare rehabilitation and surgical pathways through tear features, health, work, values, and time-sensitive tissue considerations.
• Design a task-specific return-to-work plan that does not require complete absence of pain before safe participation.

Initial presentation#

A 56-year-old right-handed building-maintenance worker visits primary care because his right shoulder remains painful and weak six weeks after a fall. He had been standing on the second step of a short ladder while changing a ceiling fixture. The ladder shifted, and he landed on his right side with the arm partly outstretched. He felt a sharp shoulder pain and a brief tearing sensation. The shoulder did not look deformed, and he did not lose consciousness.

At an urgent care center that day, there was lateral shoulder tenderness and painful movement. Distal pulses, hand sensation, and elbow and wrist movement were normal. Radiographs were reported as showing no acute fracture or dislocation, with mild acromioclavicular osteoarthritis. He was given a sling for comfort, symptom treatment, and advice to begin gentle movement. The visit note called the injury a shoulder sprain.

During the first week, bruising spread down the upper arm. He could move the right hand and elbow but could not lift a mug onto a shelf. Pain improved from severe to moderate, yet strength did not return. He stopped using the sling after several days and performed pendulum movements shown on an instruction sheet. He has not returned to overhead work. His employer now wants a date for unrestricted ladder and lifting duties.

At six weeks, he can slide the hand forward on a table and can use the left arm to raise the right arm overhead, but he cannot hold it there when the left arm lets go. Washing his hair, putting on a coat, reaching a seat belt, and sleeping on the right side remain difficult. Pain is felt over the lateral upper arm rather than in the neck. There is no fever, redness, new swelling, chest pressure, breathlessness, jaw pain, weight loss, night sweats, or pain in the opposite shoulder.

He has hypertension and well-controlled type 2 diabetes. He does not smoke and takes no anticoagulant. Before the fall, he occasionally noticed mild soreness after a day of ceiling work but had full strength and did not seek care. He has never had shoulder surgery, dislocation, injection, or cervical radiculopathy.

Examination shows no deformity, erythema, major swelling, or scapular winging. There is mild deltoid and supraspinatus-fossa contour loss compared with the other side, though guarding may contribute. The acromioclavicular joint is mildly tender but cross-body movement does not reproduce the main lateral pain.

Active forward elevation stops at about 55 degrees, while gentle passive elevation reaches 155 degrees. Active external rotation is limited and weak; passive external rotation is much better preserved. He cannot smoothly lower the arm from an assisted elevated position. Resisted abduction and external rotation are substantially weaker on the injured side, while internal rotation is relatively preserved. Elbow flexion and supination are strong, without a distalized biceps contour. Pain contributes, so the clinician repeats selected strength testing after rest rather than forcing multiple maneuvers.

Cervical motion does not reproduce arm pain. Spurling-type provocation is not compelling. Sensation over the lateral shoulder, forearm, and hand is intact. Deltoid contraction is present. Biceps, triceps, wrist, finger, and intrinsic hand strength are normal. Reflexes are symmetric. Radial pulse and hand perfusion are normal.

The key finding is not simply pain. It is a large gap between preserved passive movement and markedly impaired active elevation with objective abduction and external-rotation weakness after trauma.

Problem representation#

This is a middle-aged manual worker with a fall onto the dominant upper limb, immediate pain and later bruising, normal initial alignment and fracture radiographs, persistent inability to actively elevate the arm despite nearly preserved passive range, and objective abduction and external-rotation weakness. Distal neurovascular function and cervical screening are reassuring. Mild pre-injury soreness suggests possible pre-existing tendon degeneration, but pre-injury function was full.

The leading representation is a substantial post-traumatic rotator cuff tear, likely full thickness and possibly acute extension of a previously asymptomatic degenerative defect, with functional pseudoparesis rather than a frozen joint. Occult fracture, nerve injury, instability, and other tendon injuries remain relevant until targeted imaging and follow-up examination resolve them.

The six-week delay matters because a large traumatic tear can retract and develop muscle changes over time, while unnecessary emergency surgery also carries harm. The next step is timely shoulder-specialist assessment and tendon imaging, not a reflex promise of surgery and not months of generic therapy without defining the cause of weakness.

Prioritized differential#

1. Full-thickness rotator cuff tear#

Reasoning for: Acute pain after a fall, bruising, loss of active elevation with preserved passive range, weakness in abduction and external rotation, and inability to control lowering all support cuff failure. Supraspinatus involvement could explain elevation weakness; infraspinatus extension could explain external-rotation weakness. A large tear can produce pseudoparesis without a dislocation.

Uncertainty: Pain inhibition can mimic weakness, individual maneuvers have imperfect accuracy, and asymptomatic tears become more common with age. Imaging must show tendon integrity, retraction, muscle quality, and associated pathology. The case should not claim that every tear seen after trauma was created entirely by that trauma.

2. Occult proximal humerus, greater tuberosity, glenoid, or scapular fracture#

Nondisplaced fractures can be difficult to see on initial radiographs, particularly if views are limited. Persistent focal bone tenderness, bruising, pain with both active and passive movement, or a mechanism that fits raises this branch. CT best defines complex fracture anatomy; MRI can show marrow edema and associated soft-tissue injury. In this case passive movement is relatively preserved and the weakness pattern is more tendon-like, but fracture still needs adequate imaging review.

3. Glenohumeral dislocation or subluxation with spontaneous reduction#

A shoulder can relocate before assessment, leaving a labral injury, instability, axillary nerve injury, greater tuberosity fracture, or cuff tear. The patient did not see deformity, but that absence is not definitive. Apprehension, recurrent slipping, a dead-arm sensation, or imaging evidence would raise instability. An unreduced dislocation is an emergency and should never be sent to routine therapy.

4. Axillary nerve, suprascapular nerve, or brachial plexus injury#

Axillary nerve injury can impair deltoid power and lateral shoulder sensation after trauma or dislocation. Suprascapular neuropathy can weaken abduction and external rotation. Plexus injury produces a broader pattern. Preserved sensation, visible deltoid contraction, and isolated cuff-pattern weakness make major nerve injury less likely, but early pain and incomplete examination can conceal deficits. Persistent unexplained weakness may justify electrodiagnostic testing at a clinically useful interval.

5. Painful rotator cuff tendinopathy or partial-thickness tear without major detachment#

These are common and can follow overload or injury. Pain may inhibit movement, and active rehabilitation often helps. However, profound persistent weakness and failure to hold an assisted elevated arm are disproportionate to uncomplicated tendinopathy and justify imaging rather than assuming a subacromial pain syndrome.

6. Adhesive capsulitis#

Diabetes increases risk, and pain can precede stiffness. Adhesive capsulitis restricts both active and passive glenohumeral movement, especially external rotation. Preserved passive elevation and external rotation argue against it now. It could develop secondarily if pain leads to prolonged protection, which is one reason safe passive motion matters.

7. Cervical radiculopathy or central neurologic disease#

Neck-provoked arm pain, dermatomal sensory change, reflex asymmetry, myotomal weakness extending below the shoulder, gait findings, or upper motor neuron signs would redirect the workup. The current pattern is localized to the shoulder. A normal neck screen does not prevent reconsideration if symptoms evolve.

8. Acromioclavicular injury, biceps injury, or labral tear#

Focal superior pain and cross-body provocation support an acromioclavicular source. A proximal long-head biceps tear can produce bruising and a changed muscle contour, while labral injury can cause clicking, instability, or deep pain. These can coexist with a cuff tear but do not best explain the isolated elevation and external-rotation weakness.

9. Infection, inflammatory disease, malignancy, or referred visceral pain#

A hot red joint, fever, systemic illness, immunosuppression, recent bacteremia, or injection raises septic arthritis. Bilateral shoulder and hip stiffness could suggest polymyalgia rheumatica in the appropriate age group. A mass, unexplained weight loss, or unremitting nonmechanical pain raises malignancy. Chest pressure, breathlessness, diaphoresis, or exertional referred pain demands cardiac or thoracic assessment. None is prominent here, but a shoulder label must not erase them.

Focused history and examination#

The mechanism is reconstructed: direct impact versus outstretched arm, arm position, traction, audible pop, deformity, self-reduction sensation, immediate inability to lift, bruising, and whether strength was lost at once or after pain developed. The clinician retrieves actual radiographs and verifies that adequate views assessed the glenohumeral joint, proximal humerus, clavicle, and acromioclavicular region rather than relying only on "X-ray normal."

Pre-injury function matters. Prior pain, night symptoms, weakness, opposite-shoulder symptoms, overhead sport or work, injections, and earlier imaging help separate a new traumatic lesion from an acute-on-degenerative change. This distinction can inform prognosis and tissue quality, but it should not be used to deny that the fall changed function.

Functional questions are concrete: hair care, dressing, eating, toileting, pushing from a chair, carrying, driving, sleep, tool use, overhead reach, ladder balance, and emergency tasks at work. The clinician asks what modified duties exist and whether the employer has treated restrictions as optional.

History also covers:

• diabetes control, smoking, cardiovascular disease, infection risk, anticoagulation, and anesthesia history;
• cervical symptoms, numbness, tingling, hand clumsiness, gait change, or broader weakness;
• fever, redness, systemic symptoms, cancer history, chest symptoms, and inflammatory stiffness;
• prior physiotherapy, home exercise, immobilization duration, analgesic use, and any injection;
• the person's goals, tolerance for recovery time, caregiving duties, income protection, and access to therapy.

Examination begins with both shoulders exposed sufficiently for comparison while preserving dignity. The clinician inspects resting contour, bruising, swelling, deltoid and cuff muscle bulk, scapular position, and biceps contour. Palpation localizes clavicle, acromioclavicular joint, proximal humerus, bicipital groove, scapula, and cervical structures.

Active and passive forward elevation, abduction, external rotation, and internal rotation are compared. The scapula is observed for compensation. Strength is tested in several cuff planes with attention to pain and effort. No single maneuver is treated as diagnostic; clusters of history, motion, strength, and lag signs shift probability. Excessive repeated testing can worsen pain without adding useful information.

Neurovascular examination is recorded before and after any manipulation: hand perfusion, pulses, axillary and distal sensation, deltoid, elbow, wrist, and hand motor function. The neck and upper motor neuron screen are included when symptoms warrant. A normal hand examination alone is not a complete shoulder neurologic examination.

Diagnostic strategy#

Start by ensuring that radiographs answered the trauma question#

Radiography is the usual initial imaging for acute shoulder pain. It assesses fracture, alignment, dislocation, acromioclavicular injury, osteoarthritis, calcification, and indirect chronic cuff changes. The team reopens the original images and confirms an adequate trauma series. If views were incomplete or symptoms changed, repeat radiography is reasonable.

When radiographs are negative or indeterminate but occult fracture remains suspected, ACR criteria support CT without contrast or MRI without contrast as the next study. CT offers fine cortical and fracture-plane detail. MRI detects marrow edema and soft-tissue injuries. The choice depends on whether the unresolved question is primarily bone, tendon, labrum, or several structures.

Image the cuff when examination shows substantial traumatic weakness#

For acute shoulder pain with examination consistent with a rotator cuff tear and negative or indeterminate radiographs, shoulder ultrasound or MRI without contrast is usually appropriate according to ACR criteria. A high-quality ultrasound can dynamically assess cuff integrity and may be faster or less costly. Its accuracy depends on equipment and an experienced operator. MRI provides a broader view of tendon retraction, muscle atrophy and fatty change, marrow, biceps, labrum, cartilage, and other structures and is often useful for surgical planning.

Ordering both ultrasound and MRI automatically is unnecessary. In this case, timely ultrasound could confirm a full-thickness tear, but MRI is selected because the major loss of function, possible multi-tendon involvement, six-week interval, and surgical question require detailed tissue and muscle assessment. Contrast is not routinely needed for a straightforward native-cuff tear. MR arthrography is reserved for selected instability or labral questions and is not the default after acute trauma with a joint effusion.

Use other tests only for a defined alternative#

Electrodiagnostic studies are considered when weakness or sensory change suggests nerve injury and persists long enough for the study to answer localization and severity. They should not delay imaging of a clinically likely tendon tear. Blood tests are not routine for a mechanical cuff presentation but become important for infection, inflammatory disease, metabolic illness, or preoperative assessment.

A diagnostic injection is not used to postpone imaging of major traumatic weakness. Pain relief after local anesthetic can sometimes help separate pain inhibition from structural weakness, but injection response is not a definitive tendon test. Steroid injection has potential short-term pain benefit in selected conditions, yet timing, tendon integrity, diabetes, infection risk, prior injections, and possible surgery must be considered.

Progressive results and interpretation#

The original radiographs are technically adequate and show preserved glenohumeral alignment, no acute fracture, and mild acromioclavicular and glenohumeral degenerative change. There is no superior migration of the humeral head or other sign of longstanding massive cuff failure. This makes an unreduced dislocation and visible fracture unlikely but does not explain the weakness.

MRI shows a full-thickness supraspinatus tear extending into the upper infraspinatus, with moderate tendon retraction. There is fluid in the subacromial-subdeltoid bursa and mild long-head biceps tendinopathy. Muscle bulk is largely preserved, with only mild fatty change. There is no occult fracture, advanced glenohumeral arthritis, major labral displacement, or denervation pattern.

The imaging supports a repairable-appearing post-traumatic two-tendon tear and explains the examination. Mild fatty change and the prior intermittent soreness suggest that some tendon degeneration preceded the fall. Preserved muscle bulk and the sudden functional loss support an acute extension that made the lesion clinically important. The report is framed as acute traumatic loss of function with imaging evidence of a full-thickness tear on a background of tendon degeneration, not a false choice between entirely new and entirely old.

The primary clinician contacts a shoulder orthopedic service rather than scheduling months of routine care first. During consultation, active elevation remains substantially limited, while passive motion is preserved. The surgeon explains that many cuff tears can improve with nonoperative care, but recent trauma, marked weakness, multi-tendon full-thickness tearing, functional demands, and tissue retraction make timely repair a reasonable option. Diabetes, work, rehabilitation access, and the risks of surgery are included.

The patient values independent self-care and overhead work and wants the strongest chance of restoring active elevation. He also fears months without full wages. After discussing a structured rehabilitation option, surgical repair, expected protection and therapy, uncertainty, retear risk, stiffness, infection, anesthesia, and the possibility of persistent symptoms, he chooses arthroscopic repair. This is a preference-sensitive decision, not proof that every similar tear requires surgery.

At surgery, the tear is mobile enough for repair. The biceps and other findings are managed according to direct operative assessment. Exact technique is not prescribed here. Postoperative rehabilitation follows the surgeon and therapist's tear-specific protocol. Protection of tendon healing is balanced against stiffness prevention, and progression is not accelerated to satisfy an employer's generic deadline.

Management plan#

Protect function before the final treatment decision#

The patient avoids unsupported overhead lifting, ladder work, heavy carrying away from the body, and tasks in which sudden weakness could injure him or another person. The shoulder is not kept motionless. Gentle passive and assisted movement within a clinician-directed range helps preserve mobility while imaging and consultation occur. A sling may be used briefly for comfort or protection but prolonged unstructured use increases stiffness and dependence.

Pain treatment supports sleep and safe movement and is individualized to kidney, liver, gastrointestinal, cardiovascular, and medication risks. Exact drug schedules are omitted. Ice or heat can be used according to comfort and skin safety. The clinician does not recommend exercising through sharp pain or using analgesia to prove work readiness.

Offer a real nonoperative pathway#

Nonoperative care can include education, activity modification, an active task-oriented rehabilitation program, and selected symptom treatment. Physiotherapy addresses passive and active motion, scapular control, deltoid and remaining cuff capacity, graded resistance, confidence, and the tasks the person wants to regain. Progress is measured through pain, active elevation, strength, sleep, self-care, and work function.

For degenerative or smaller tears, older or medically frail patients, people with acceptable function, or those who prefer to avoid surgery, this pathway may provide good outcomes. Tendon anatomy may not heal, yet function can improve through pain reduction and compensation. The tradeoff is that some tears can enlarge or develop muscle change, while surgery carries its own risks and repair can fail.

A steroid injection is not a compulsory step. It may offer short-term pain relief for selected patients and can help participation in rehabilitation, but it does not reattach tendon. Repeated injections may have tissue and surgical implications. Infection risk, diabetes, timing, and the diagnostic question are considered with the treating team.

Define when surgical consultation adds value#

Early shoulder-specialist input is valuable for substantial traumatic weakness, acute loss of active elevation, a repairable full-thickness tear, multi-tendon involvement, tissue retraction, high functional demand, or failure of an appropriate rehabilitation trial. Referral does not equal operation. It creates the opportunity to discuss whether delay could reduce repairability and whether expected benefit justifies burden and risk.

Surgical decision factors include traumatic versus gradual onset, tear size and pattern, retraction, muscle quality, age, diabetes and smoking, arthritis, nerve function, pre-injury activity, current disability, goals, caregiving, work, ability to complete rehabilitation, and the person's preferences. Chronologic age or job title alone does not decide.

Make postoperative care and work planning one continuum#

After repair, the surgeon and physiotherapist specify sling use, passive and active movement phases, strengthening, lifting limits, wound care, driving, sleep positions, and signs of complications. Protocols vary by tear size, tissue quality, fixation, associated procedures, and surgeon preference. A protocol for a small tear cannot be copied onto a multi-tendon repair.

Occupational planning begins before surgery. Early modified duties might include planning, inventory, telephone coordination, or inspection below shoulder height if medication, sling, balance, transport, and workplace safety permit. Ladder climbing, overhead electrical work, emergency lifting, and power tools require later task-specific strength, endurance, control, and repair clearance. The employer receives functional restrictions, not unnecessary diagnostic detail.

Diabetes care, smoking avoidance, nutrition, sleep, and attendance barriers are addressed because healing occurs within the whole health context. Therapy frequency is adapted to transport and coverage without replacing skilled milestones with unsupported internet exercises.

Escalation, referral, and safety net#

Same-day emergency assessment is required for deformity or suspected unreduced dislocation, an open injury, absent or markedly reduced pulse, a cold or pale hand, rapidly expanding swelling, severe uncontrolled pain, new dense numbness, or progressive arm paralysis. A hot red shoulder with fever or systemic illness raises joint infection. Chest pain, breathlessness, diaphoresis, or jaw and arm symptoms require emergency cardiopulmonary assessment rather than a shoulder clinic.

Urgent musculoskeletal or orthopedic assessment is appropriate after trauma when a person suddenly cannot actively raise the arm, has substantial objective weakness, has a suspected tendon rupture, or has persistent disability despite negative initial radiographs. New mass, unexplained weight loss, night sweats, or relentless nonmechanical pain requires a tumor or systemic pathway.

After surgery, urgent contact is needed for fever, increasing wound redness or drainage, rapidly escalating pain or swelling, new hand coldness or numbness, chest pain, breathlessness, or a sudden loss of function after another injury. A "pop" alone has several explanations, but a pop with new weakness warrants assessment. Pain and sleep disturbance are expected to some degree and should be discussed without either normalizing dangerous change or directing every fluctuation to an emergency department.

If nonoperative care is chosen, worsening weakness, declining active elevation, new instability, increasing rest pain, or failure to progress at an agreed checkpoint triggers reassessment of diagnosis, adherence barriers, imaging, nerve function, and treatment preference. Open-ended therapy without a checkpoint is not accountable care.

Communication, shared decisions, and equity#

The clinician explains the active-passive distinction: "Your joint can be moved much farther than you can lift it yourself. That tells us the shoulder is not simply frozen. Pain can reduce strength, but after this fall the pattern also raises concern that one or more tendons are no longer transmitting force normally. The X-ray was useful for bones and alignment; it could not directly show those tendons."

Imaging language is handled carefully. Degeneration does not mean the pain is imaginary or that trauma is irrelevant. Many adults have tendon changes without symptoms. A fall may create a new tear, extend an older one, or make a silent defect symptomatic. The clinician describes what can and cannot be inferred and avoids acting as an employment or legal causation expert beyond the clinical evidence.

Shared decision making includes more than a list of surgical complications. The patient compares time to improvement, rehabilitation burden, likelihood of restoring overhead strength, possibility of acceptable nonoperative function, risk of tear progression or repair failure, time away from driving and work, sleep, caregiving, and personal tolerance for uncertainty. Teach-back checks understanding.

Work status can create pressure from both employer and worker. A self-employed or hourly worker may return before safe; a workplace may withhold modified duty; an insurer may equate imaging degeneration with no injury. The clinician documents observed function and task restrictions neutrally. Social work, occupational health, or vocational rehabilitation helps with wage, transport, and modification barriers where available.

Language access, health literacy, disability, gender, and race can affect whose pain and weakness are taken seriously and who reaches imaging or specialist care. A professional interpreter, accessible exercise materials, and explicit follow-up ownership reduce those gaps. The examination respects pain and does not repeatedly demand a dramatic failed movement as proof.

Follow-up and contingencies#

Before definitive treatment, follow-up records pain, sleep, passive and active range, strength in comparable positions, neurovascular status, self-care, work capacity, and whether the person can complete the proposed plan. Imaging and referrals have named owners. If a report suggests a full-thickness traumatic tear, the patient is contacted directly rather than waiting for a routine portal check.

After surgical repair, milestones are individualized. Early assessment focuses on wound, pain, hand and elbow function, sling fit, safe passive movement, medication effects, sleep, and infection or neurovascular signs. Later phases add active control, range, progressive resistance, endurance, and task simulation. Imaging is not obtained routinely just to explain every slow week; it is used when reinjury, repair failure, stiffness, infection, or another complication is clinically plausible and the result will change care.

If nonoperative management is selected, a structured rehabilitation trial has goals and a reassessment point. Improvement can mean better sleep, more active elevation, safer self-care, increasing resistance, and return to valued tasks even if the tendon remains torn. Lack of progress leads to reassessment rather than blame.

Return to work uses a task inventory:

• Desk and coordination tasks: assess medication, comfort, keyboard or phone use, sling restrictions, and transport.
• Waist-level light tasks: assess two-handed control, carrying close to the body, repetition, and ability to avoid sudden loads.
• Overhead and ladder tasks: require adequate active elevation, strength, endurance, balance, reaction to unexpected load, and treating-team clearance.
• Emergency or safety-critical tasks: require a margin beyond performing one movement once in a clinic.

Four contingency branches remain explicit:

• Rehabilitation restores acceptable function without surgery: Continue progressive loading, self-management, and work conditioning while monitoring any new loss of strength.
• Weakness persists despite a credible rehabilitation trial: Reassess tear progression, nerve function, stiffness, goals, and surgical options.
• Passive motion becomes restricted: Evaluate secondary adhesive capsulitis, pain behavior, diabetes, and whether rehabilitation intensity needs adjustment.
• A new injury causes sudden decline: Repeat examination and imaging as indicated for retear, fracture, dislocation, or nerve injury; do not assume it is ordinary postoperative pain.

Long-term care supports both shoulders, trunk and lower-limb capacity for ladder safety, ergonomic task design, paced overhead work, and early reporting of recurrent weakness. Prevention is not a promise that all age-related tendon change can be stopped.

Reasoning traps and alternative pathways#

• Stopping after a normal radiograph: A useful bone and alignment study does not show most cuff tears and may miss an occult fracture.
• Calling all post-fall pain a sprain: Persistent objective weakness or loss of active elevation requires a new problem representation.
• Confusing active and passive restriction: Markedly reduced passive motion supports joint stiffness; preserved passive motion with poor active control points toward pain, tendon, muscle, or nerve dysfunction.
• Using one special test as proof: Shoulder maneuvers overlap and are affected by pain. A pattern is more reliable than one named test.
• Assuming every MRI abnormality is new: Degenerative tendon findings are common. Mechanism, pre-injury function, muscle quality, and current deficits determine relevance.
• Assuming degeneration makes trauma irrelevant: An injury can extend or activate a pre-existing asymptomatic lesion and cause a real functional loss.
• Sending major traumatic weakness through prolonged generic therapy first: Rehabilitation is valuable, but delay can matter when a repairable acute tear is plausible.
• Treating referral as consent to surgery: Specialist consultation should offer a genuine comparison of operative and nonoperative paths.
• Using an injection as a diagnostic shortcut: Symptom response does not establish tendon integrity, and injection choice must consider timing, diabetes, infection, tissue, and surgery.
• Clearing work by date alone: Overhead and safety-critical tasks require demonstrated strength, endurance, control, and protection of healing tissue.

An alternative pathway would emerge if repeat imaging showed a nondisplaced greater tuberosity fracture. Load protection and orthopedic fracture management would replace early cuff strengthening, while associated cuff injury could still be assessed. A dislocation would require reduction, post-reduction radiographs, and neurovascular re-examination.

If the deltoid were weak with lateral-shoulder sensory loss, axillary nerve injury would rise and electrodiagnostic and specialist follow-up would be planned. Broader weakness, reflex change, or neck-provoked symptoms would elevate cervical radiculopathy. Marked loss of passive external rotation over time would suggest adhesive capsulitis and change rehabilitation emphasis.

A hot swollen shoulder with fever would require aspiration and infection management rather than injection or routine exercise. Exertional chest and shoulder discomfort would be treated as possible cardiac disease until appropriately assessed. An unexplained mass or destructive bone lesion would activate malignancy investigation.

Evidence limits and what could change#

Rotator cuff tears are heterogeneous. Trials often mix traumatic and degenerative tears, different sizes, ages, chronicity, rehabilitation programs, and surgical techniques. Imaging abnormalities are common in asymptomatic adults, so structural diagnosis must be linked to clinical function. Evidence for one group cannot be transferred uncritically to every acute traumatic multi-tendon tear.

The AAOS 2025 guideline synthesizes current evidence across adult cuff injuries, while ACR criteria guide imaging selection. The 2025 rotator cuff tendinopathy guideline focuses mainly on tendinopathy, calcification, and partial-thickness tears rather than the complete management of acute traumatic full-thickness tears. The 2022 return-to-work guideline provides task-oriented principles but arose within a specific health and compensation context.

Ultrasound and MRI can both diagnose full-thickness tears when performed and interpreted well. Availability, operator expertise, body habitus, range of motion, suspected associated injury, implant status, and surgical planning influence selection. MRI estimates retraction and muscle quality but cannot perfectly date a tear or guarantee repairability.

Surgery may improve pain and function for selected patients, but repair can fail structurally, rehabilitation is long, and nonoperative care can provide acceptable function. Conversely, long delay in a large acute tear may allow retraction and muscle change. This uncertainty is why early consultation and shared decisions are more defensible than a universal operation or universal therapy rule.

Injection evidence and surgical implications continue to evolve. The number, timing, product, tissue status, infection risk, and metabolic effects matter. This case avoids operational injection or medication instructions. Postoperative movement timing also varies with tear size, tissue quality, fixation, and associated procedures despite evidence supporting more than one approach in selected tears.

Key points#

• Persistent inability to raise an arm after a fall deserves reassessment even when initial radiographs show no fracture or dislocation.
• Comparing active with passive movement helps distinguish joint stiffness from weakness, tendon failure, pain inhibition, and nerve dysfunction.
• Ultrasound or MRI is usually appropriate when examination suggests a rotator cuff tear after negative or indeterminate radiographs; MRI may better support complex or surgical planning.
• Imaging can show an acute-on-degenerative tear. Pre-existing tendon change does not negate a new post-traumatic functional loss.
• Not every full-thickness tear requires surgery, but substantial recent traumatic weakness and a repairable multi-tendon tear justify timely specialist discussion.
• Rehabilitation, work modification, diabetes and health optimization, and task-specific return planning matter in both operative and nonoperative pathways.

Sources#

1. American Academy of Orthopaedic Surgeons: 2025 Management of Rotator Cuff Injuries Guideline
2. American College of Radiology: Appropriateness Criteria for Acute Shoulder Pain
3. American College of Radiology: Appropriateness Criteria for Chronic Shoulder Pain
4. Rotator Cuff Tendinopathy Diagnosis, Nonsurgical Medical Care, and Rehabilitation Guideline
5. Diagnosing, Managing, and Supporting Return to Work of Adults With Rotator Cuff Disorders
6. British Elbow and Shoulder Society: Subacromial Shoulder Pain Commissioning Guide
7. AAOS OrthoInfo: Rotator Cuff Tears
8. AAOS OrthoInfo: Shoulder Dislocation
9. AAOS OrthoInfo: Shoulder Trauma, Fractures and Dislocations
10. NHS: Shoulder Pain Recognition and Urgent Assessment