A 52-year-old comes in with a right shoulder that started aching eight months ago without any injury. He cannot sleep on it. An orthopedist called it impingement, a cortisone shot helped for three weeks, and six weeks of physical therapy did nothing he could feel. The MRI report lists a partial-thickness supraspinatus tear, bursal fluid, AC joint arthropathy, and a labral signal change. None of that says which structure hurts. The examination does: in his case passive external rotation was half of the other side, which makes it a capsule problem — early frozen shoulder — and a subacromial cortisone shot was never going to fix it.
That is the reason a shoulder pain visit at Modal Pain Management starts with a sorting question rather than a treatment. Five conditions produce shoulder pain that feels the same from the inside, and each responds to a different procedure. Dr. Alex Movshis separates them at the consultation by examination and bedside ultrasound, treats the one that is actually the source, and refers the cases that need a surgeon. This page walks through the five, the red flags that skip the line, what gets injected and what does not, and what to expect at the visit.
Five shoulders that look the same from the outside
Frozen shoulder (adhesive capsulitis). The joint capsule — the fibrous sleeve around the ball-and-socket — inflames, thickens, and contracts. The signature is loss of passive range of motion: the shoulder is stiff even when someone else moves it, and external rotation goes first. Night pain is severe and early. It peaks between 40 and 60, more often in women, and is several times more common with diabetes and thyroid disease. The 2013 clinical practice guideline on adhesive capsulitis (Kelley 2013) supports an intra-articular corticosteroid injection combined with mobility work for short-term pain and function, with the evidence strongest early in the course, which is why the diagnosis has to be made early and not after months of subacromial injections aimed at the wrong tissue. Our 45-second frozen shoulder film shows the mechanism. At Modal Pain the first procedure is an ultrasound-guided glenohumeral corticosteroid injection, and a suprascapular nerve block when the night pain is stopping sleep.
Rotator cuff tendinopathy and subacromial bursitis. The supraspinatus tendon and the bursa above it are compressed under the acromion with every overhead reach. Pain sits on the outer shoulder, is worst reaching overhead or lying on that side, and has a painful arc between about 60 and 120 degrees of elevation. Passive motion is preserved, which is the finding that separates it from frozen shoulder. Weakness on the empty-can or external-rotation tests raises the question of a tear. This is the most common shoulder diagnosis after 40 and the subject of its own page: shoulder bursitis and rotator cuff tendinopathy, including the exercise-first evidence from the MOON shoulder group (Kuhn 2013), the ultrasound-guided subacromial injection, and PRP for the chronic tendon.
Suprascapular nerve entrapment. The nerve that supplies the supraspinatus and infraspinatus passes through two notches on the shoulder blade, and it can be compressed at either by a thickened ligament, a cyst from a labral tear, or repetitive overhead traction in swimmers, volleyball players, and weightlifters. The pain is a deep, poorly localized ache at the back and top of the shoulder that does not behave like a cuff problem — no painful arc, no relief from a subacromial injection — with weakness lifting the arm out to the side or rotating it outward, and in longer-standing cases visible wasting of the infraspinatus below the spine of the scapula. An ultrasound-guided suprascapular nerve block is both the test and the first treatment, and radiofrequency ablation of the nerve extends the relief when the block works but wears off. The full picture is on our suprascapular nerve entrapment guide.
Referred pain from the neck. A C5 or C6 nerve root irritated by a disc or a bone spur sends pain into the shoulder and the outer arm, and a cervical facet joint refers pain to the top of the shoulder and the inner edge of the shoulder blade. The tells are that the pain travels past the shoulder, that turning or tilting the head reproduces it, that there is tingling or numbness in the hand, and that the shoulder itself examines normally. Dr. Movshis examines the neck on every shoulder patient because this pattern is the one most often treated with a shoulder injection that cannot work. The treatment is a cervical epidural steroid injection for the nerve root, or a medial branch block and radiofrequency ablation when the facet is the source, both through our neck pain pathway. Our guide to a pinched nerve in the neck covers how to tell.
The joints: AC and glenohumeral arthritis. Acromioclavicular joint pain sits on the very top of the shoulder over the bump where the collarbone meets the shoulder blade, is reproduced by reaching across the chest and by bench press and dips, and is common in weightlifters and after a separation. Glenohumeral osteoarthritis produces a grinding, stiff shoulder in patients usually over 60, and looks like frozen shoulder on exam until the X-ray shows the joint space narrowing. Both respond to an ultrasound-guided joint injection — the AC joint is small and blind injections miss it about a third of the time — and advanced glenohumeral arthritis is referred for a surgical opinion once injections stop lasting. Our joint pain page covers the arthritis pathway.
Pain between the shoulder blades belongs to a different list — rhomboid and middle trapezius trigger points, cervical facet referral, a thoracic facet or rib joint — and is covered in our guide to pain between the shoulder blades, with trigger point injections as the usual first procedure when exercise has not settled it.
The red flags that skip the sorting
Left shoulder or arm pain with chest pressure, sweating, shortness of breath, or nausea is a heart problem until proven otherwise, and the right move is 911, not a shoulder appointment. Shoulder pain after a fall or a sudden lifting injury with visible deformity, inability to lift the arm, or immediate marked weakness needs same-day imaging for dislocation, fracture, or an acute full-thickness cuff tear. A hot, swollen shoulder with fever is a joint infection until excluded. Night pain that is unrelieved by any position in a smoker or a patient with weight loss, or shoulder pain with a drooping eyelid and a small pupil on the same side, needs a chest X-ray for a tumor at the top of the lung. We see these rarely, and we send them to the right place the same day.
Why the examination and ultrasound settle it
No single shoulder test makes a diagnosis. The largest meta-analysis of shoulder examination tests concluded that none can be recommended alone, and that combinations of history and examination findings do better than any individual maneuver (Hegedus 2012). That is how the sorting above works: the direction of motion loss, the painful arc, the strength tests, the neck maneuvers, and the location of tenderness are read together, and the pattern is then confirmed on ultrasound in the same room. Ultrasound shows the rotator cuff tendons, the subacromial bursa, the biceps tendon, the AC joint, and the suprascapular notch, dynamically, while you move — something MRI cannot do — and it then guides the needle. In a pooled analysis of shoulder injection studies, ultrasound guidance placed the injection correctly in 92.5% of glenohumeral injections versus 72.5% by landmarks, in 93.6% of AC joint injections versus 68.2%, and in 86.7% of biceps sheath injections versus 26.7% (Aly 2015). A shoulder injection that missed is indistinguishable from a shoulder injection into the wrong structure, and both send patients down the road of “cortisone didn’t work.”
MRI has a different job. It is the test for surgical planning, for a suspected full-thickness tear in an active patient, and for the labrum. It is a poor test for “what hurts,” because abnormal findings are the norm in shoulders that do not hurt: in 96 people with no shoulder symptoms, 34% had a rotator cuff tear on MRI, and 54% of those over 60 did (Sher 1995). If you already have an MRI, bring it. It is read alongside the exam.
What gets injected here, and what does not
Corticosteroid is the fast tool. Placed under ultrasound into the subacromial bursa, the glenohumeral joint, or the AC joint, it reduces inflammation within days and buys weeks to months of function, which is what a bursitis flare, an early frozen shoulder, or an arthritic joint needs. It is not repeated into a tendon, because repeated steroid weakens tendon, and it is not the answer for a chronic degenerated rotator cuff. PRP is the slow tool: platelet-rich plasma injected into a chronically degenerated supraspinatus or a partial-thickness tear matures over 6–12 weeks and is chosen for durability. Nerve procedures are for the nerve problems: a suprascapular nerve block for entrapment and for the night pain of frozen shoulder, radiofrequency ablation when the block works and wears off. Cervical procedures are for the neck: the epidural for the nerve root, the medial branch block and ablation for the facet. Every one is placed under ultrasound or fluoroscopy, takes 10–15 minutes, and you use the arm the same day.
What we do not do is surgery, and knowing when to refer for it is part of the visit. A full-thickness, retracted rotator cuff tear in a patient under 65 who wants to keep using the arm overhead is repaired better early, before the muscle turns to fat and the repair stops holding. Recurrent dislocation, a large labral tear in a young athlete, and glenohumeral arthritis that has stopped responding to injections are surgical problems. We say so at the first visit and send the exam and ultrasound findings with the referral. Physical therapy runs alongside every pathway on this page, and the physical therapy page describes how the referral works.
What to expect at Modal Pain Management
The first visit is a 45-minute consultation. Bring any imaging you have and the list of what has been tried. Dr. Movshis takes the history, examines the shoulder and the neck, scans the shoulder with ultrasound at the same visit, and tells you which of the five it is and why. If an injection is indicated it is typically scheduled within 1–2 weeks at the same office, and physical therapy is arranged to start once the injection has settled the pain enough to load the shoulder. Follow-up at 4–6 weeks measures the response and decides whether the plan holds, escalates to PRP or a nerve procedure, or goes to a surgical opinion. The consultation, ultrasound, and image-guided procedures are covered by most commercial PPO plans, some with prior authorization that our office handles. PRP is self-pay and, like every procedure, is priced on the pricing page. We do not participate with Medicare or Medicaid. You can verify your insurance before the visit.
If your shoulder has had a cortisone shot that did not last, or a physical therapy course that did not change anything, the structure was probably never identified. That is the visit to book.
References
- Hegedus EJ, Goode AP, Cook CE, et al. Which physical examination tests provide clinicians with the most value when examining the shoulder? Update of a systematic review with meta-analysis of individual tests. Br J Sports Med. 2012;46(14):964–978. doi:10.1136/bjsports-2012-091066
- Aly AR, Rajasekaran S, Ashworth N. Ultrasound-guided shoulder girdle injections are more accurate and more effective than landmark-guided injections: a systematic review and meta-analysis. Br J Sports Med. 2015;49(16):1042–1049. doi:10.1136/bjsports-2014-093573
- Kelley MJ, Shaffer MA, Kuhn JE, et al. Shoulder pain and mobility deficits: adhesive capsulitis. Clinical practice guidelines linked to the International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association. J Orthop Sports Phys Ther. 2013;43(5):A1–A31. doi:10.2519/jospt.2013.0302
- Kuhn JE, Dunn WR, Sanders R, et al. Effectiveness of physical therapy in treating atraumatic full-thickness rotator cuff tears: a multicenter prospective cohort study. J Shoulder Elbow Surg. 2013;22(10):1371–1379. doi:10.1016/j.jse.2013.01.026
- Sher JS, Uribe JW, Posada A, Murphy BJ, Zlatkin MB. Abnormal findings on magnetic resonance images of asymptomatic shoulders. J Bone Joint Surg Am. 1995;77(1):10–15. doi:10.2106/00004623-199501000-00002
