Differential Diagnosis for Shoulder Pain

Age-Based Diagnostic Framework

In patients over 35-40 years, the American College of Radiology suggests that rotator cuff disease, degenerative changes, and arthritis are the predominant causes of shoulder pain, while patients under 35 years should be evaluated primarily for instability, labral tears, and sports-related injuries 1
The American College of Radiology recommends considering rotator cuff tendinopathy or tear, which presents with pain during overhead activities, weakness with abduction and external rotation, and positive empty can test, in patients over 35-40 years 1
Subacromial impingement syndrome should be considered in patients with pain with overhead activities, narrowing of subacromial space, and positive impingement signs, according to the American College of Radiology 2
Glenohumeral osteoarthritis is a progressive condition characterized by pain, decreased range of motion, and crepitus, as noted by the Journal of the American College of Radiology 3
Acromioclavicular joint arthritis presents with superior shoulder pain, tenderness over the AC joint, and pain with cross-body adduction, as reported by the American College of Radiology 2
Adhesive capsulitis, or frozen shoulder, is characterized by progressive stiffness and global loss of passive and active range of motion, according to the Journal of the American College of Radiology 3

The American College of Radiology suggests that fractures, including proximal humerus, clavicle, scapula, or glenoid fractures, should be considered in patients with traumatic shoulder pain, and to assess the mechanism, height of fall, and landing position 1
Glenohumeral dislocation, which can be anterior, posterior, or inferior, is characterized by visible deformity, severe pain, and inability to move the shoulder, as noted by the Journal of the American College of Radiology 5, 4
Acromioclavicular separation presents with a direct blow to the shoulder, visible step-off deformity, and tenderness over the AC joint, according to the Journal of the American College of Radiology 3
Bankart lesion, an anterior labral tear with or without a bony fragment, is associated with anterior dislocation, as reported by the Journal of the American College of Radiology 4
Hill-Sachs lesion, a posterolateral humeral head compression fracture, occurs from anterior dislocation, according to the Journal of the American College of Radiology 4
Rotator cuff tear can occur as an acute tear from a fall or trauma, particularly in patients over 40 years, as noted by the Journal of the American College of Radiology 5

Septic arthritis is a medical emergency characterized by fever, severe pain, warmth, erythema, and constitutional symptoms, requiring urgent arthrocentesis, as reported by the Journal of the American College of Radiology and the American College of Radiology 3, 6
Osteomyelitis presents with persistent pain, fever, and elevated inflammatory markers, according to the Journal of the American College of Radiology 3
Malignancy, including primary bone tumor or metastatic disease, can cause shoulder pain, and is characterized by unexplained weight loss, night pain, and pathologic fracture, as noted by the Journal of the American College of Radiology 5
Massive rotator cuff tear is an acute complete tear that requires expedited repair for optimal outcomes, according to the American College of Radiology 6

Crystalline arthropathy, including gout or pseudogout, can affect the glenohumeral joint, as reported by the Journal of the American College of Radiology 3
Avascular necrosis can cause shoulder pain, particularly in patients with a history of corticosteroid use, alcohol abuse, or sickle cell disease, according to the Journal of the American College of Radiology 3

The American College of Radiology suggests that assuming the absence of trauma excludes fracture is a critical error, as osteoporotic fractures can occur with minimal or unrecognized trauma in elderly patients 1
Missing acromioclavicular or glenohumeral dislocations on AP views alone is a common pitfall, and scapular Y or axillary views are essential, as noted by the Journal of the American College of Radiology 4
Failing to assess for scapular dyskinesis is a critical error, as poor scapular mechanics contribute to and result from rotator cuff pathology, according to the American College of Radiology 1