Similar Shoulder Pain – Two Patients, Two Opposing Clinical Patterns

In clinical practice, patients frequently present with very similar shoulder complaints:
pain during arm elevation, difficulty with daily activities, disturbed sleep.

However, identical symptoms can arise from fundamentally different mechanisms.

his case analysis compares two patients presenting with analogous shoulder pain and demonstrates why clinical pattern recognition matters more than symptoms alone.

Patient A – Stiff and Unstable

46-year-old male, software developer, attends the gym twice weekly

Main complaint:

“I can’t lift my arm properly – it feels stiff and heavy.”

body chart:

24h-behaviour:

• Arm elevation: persistently stiff and heavy
• Reaching behind the back: painful and restricted
• Right side-lying: clicking and night pain
• Planks and press-ups: painful or impossible

History:
Forward fall while skiing (flexion mechanism). Rapid initial improvement followed by a clear plateau. Several physiotherapy episodes and strengthening attempts without lasting benefit.

Objective findings – hypothesis testing

Evidence of posterior tightness

• Inspection: humeral head positioned anteriorly at rest

• Active flexion and abduction: stiff, limited glenoid fol

• Internal rotation at 90° abduction: restricted; External rotation at 90° abduction: painful
• muscle function testing for infraspinatus and subscapularis

        (if you like we can the ratio between medial and lateral rotators as well as taking the dominant and non-dominant arm into consideration)

• Passive testing:
  • stiff horizontal flexion and restricted internal rotation at 90° abduction
  • during IR at 45° abduction, the humeral head translates anteriorly

➡️ Movement is restricted and compensated.

Evidence of dynamic anterior instability

• Apprehension and Relocation test: positive

• Anterior drawer: positive

➡️ Active centring fails under load.

Clinical pattern – Patient A

Posterior tightness combined with dynamic anterior instability

Restricted posterior structures limit available motion.
Insufficient dynamic control allows anterior translation when load is applied.

This explains:

• why mobilisation alone aggravates symptoms
• why strengthening alone is poorly tolerated

Patient B – Painful and Unstable

60-year-old female, nursery teacher, recreational volleyball player

Main complaint:
Pain during arm elevation.

body chart:

Symptom behaviour

• Washing and reaching the other shoulder: painful
• Dressing: painful
• Overhead reaching (cups, plates): painful
• Sleeping on the left side: painful
• Press-ups: impossible

History:
Direct blow to the arm during volleyball. Progressive worsening despite physiotherapy. Corticosteroid injection without effect, followed by oral corticosteroids. Plain radiographs unremarkable.

Objective findings – hypothesis revision

Initial assumption: posterior tightness?

• Inspection: atrophy of infraspinatus

• Active flexion and abduction: painful and limited

• Internal and external rotation at 90° abduction: painfu

• Passive horizontal flexion and IR appear restricted

However:

• no firm or hard end feel
• movement stops primarily due to pain

Key observation

• Palpable subluxation of the humeral head during testin

• Inspection: visible infraspinatus atrophy

➡️ Movement does not stop because of stiffness, but because the joint cannot maintain position.

Evidence of posterior instability

• Sulcus sign: positive

• Posterior drawer: positive

• • clear posterior translation:
    

➡️ Confirms a clinically relevant posterior instability pattern.

Clinical pattern – Patient B

Posterior instability with pain-dominant presentation

Unlike Patient A, mobility is not mechanically restricted.
The dominant feature is posterior instability combined with high irritability.

Apparent limitations in internal rotation and horizontal flexion are primarily pain-driven, without a firm capsular end feel. Movement stops because the joint cannot maintain congruency — not because posterior structures are shortened.

Positive sulcus sign and posterior drawer confirm clinically relevant posterior translation. Palpable subluxation during testing and visible infraspinatus atrophy further support insufficient posterior cuff contribution and reduced dynamic stabilization.

This explains:

• why symptoms progressively worsened

• why mobilisation approaches may aggravate rather than improve

• why corticosteroid treatment reduced inflammation but did not resolve the mechanical driver

In contrast to Patient A, translation is not compensatory — it is the primary dysfunction.

Key clinical messages

• Symptoms alone do not define the problem
• Reduced motion does not equal stiffness
• Painful restriction may reflect instability, not tightness
• Improving mobility where control is lacking often escalates symptoms
• The key clinical question is:
  Is movement limited by tissue, or by the inability to control it?

Final thought

Clinical expertise is not about confirming hypotheses –
it is about abandoning them when the findings no longer fit.

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