From the Guidelines
The patient's symptoms and X-ray findings suggest rotator cuff pathology and AC joint arthritis as potential causes of symptoms, and initial treatment should include rest, ice, and over-the-counter anti-inflammatories, with consideration of further imaging with MRI if symptoms persist. The left shoulder X-ray shows no fracture or dislocation, but there are several findings that may explain shoulder pain, including calcification near where the rotator cuff attaches to the humeral head, which could indicate tendinitis or enthesopathy (inflammation where tendons attach to bone) 1. The AC joint shows mild to moderate arthritis, and there may be some general soft tissue swelling in the shoulder area.
According to the American College of Radiology (ACR) Appropriateness Criteria, MRI is the procedure of choice for evaluating occult fractures and shoulder soft tissues, including tendons, ligaments, muscles, and labrocapular structures 1. Ultrasound can also be used to evaluate the acromioclavicular joint, the tendons of the rotator cuff, and the long head of biceps tendon, and is excellent in the depiction of rotator cuff and long head of biceps pathology in the preoperative and postoperative shoulder 1.
The patient's treatment plan should prioritize reducing pain and inflammation, and improving range of motion and strength. This can be achieved through:
- Rest and avoiding activities that worsen pain
- Ice for 15-20 minutes several times daily
- Over-the-counter anti-inflammatories like ibuprofen (400-600mg three times daily with food) or naproxen (500mg twice daily)
- Physical therapy focusing on gentle range of motion and rotator cuff strengthening exercises If symptoms persist beyond 2-3 weeks despite these measures, follow-up with an orthopedic specialist would be appropriate to consider additional treatments such as corticosteroid injections or further imaging with MRI to better evaluate the rotator cuff 1.
From the Research
Diagnosis and Treatment of Shoulder Pain
The left shoulder x-ray shows normal glenohumeral alignment, no acute fracture, and subtle dystrophic calcification along the superolateral humeral head, which may relate to rotator cuff insertion calculations/enthesopathy and/or calcification tendinitis. The following points summarize the possible diagnosis and treatment options:
- Calcific tendinitis of the rotator cuff is a common disorder, and its underlying mechanism remains unknown 2, 3.
- The condition can be classified into formative and resorptive phases, with the resorptive phase being severely painful 4.
- Conservative treatment includes pain killers, physiotherapy, and minimally invasive techniques such as needling or puncture and aspiration 4.
- Arthroscopic removal is an option for patients with intolerable pain in the acute and severely painful resorptive stage 4.
- Ultrasound is an important tool in the diagnostic and therapeutic pathway, especially when surgery is being considered 5.
- The diagnosis and management of shoulder pain require a thorough history, physical examination, and imaging signs, including X-ray, ultrasound, and magnetic resonance imaging 5, 6.
- Treatment options include physiotherapy, anti-inflammatory medication, local corticosteroid injections, and surgical intervention in some cases 5, 6.
Possible Causes of Shoulder Pain
The following points summarize the possible causes of shoulder pain:
- Impingement syndrome
- Adhesive capsulitis
- Calcified tendonitis
- Cervical radiculopathy
- Glenohumeral osteoarthritis
- Biceps tendonitis
- Subdeltoid subacromial bursitis
- Glenohumeral joint capsulitis
- Long head of biceps tendinosis
- Acromioclavicular joint osteoarthritis 5, 6
Treatment Options
The following points summarize the treatment options for shoulder pain: