What are the differential diagnoses for a child with acute painful right shoulder and inability to use the right arm after playing outdoors, with normal plain radiographs?

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Last updated: September 27, 2026 • View editorial policy

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Differential Diagnoses for Pediatric Shoulder Trauma with Normal Radiographs

In a child with acute shoulder pain and inability to use the arm after trauma with normal x-rays, the most likely diagnoses are soft tissue injuries including rotator cuff tears, labral tears, glenohumeral instability (subluxation/dislocation with spontaneous reduction), occult fractures (particularly proximal humerus or greater tuberosity), physeal injuries, acromioclavicular sprains, and bone marrow contusions.

Primary Differential Considerations

The key differentials in this clinical scenario, based on the most recent imaging guidelines 1, include:

Soft Tissue Injuries (Most Common)

  • Rotator cuff tears: Common in pediatric shoulder trauma despite normal radiographs 2, 3
  • Labral tears: Frequently missed on plain films but cause significant functional impairment
  • Glenohumeral instability: Including subluxation or dislocation with spontaneous reduction before imaging 2
  • Capsular and ligament tears: Extra-articular soft tissue injuries that plain radiographs cannot detect 1, 4

Occult Bony Injuries

  • Physeal injuries: MRI has been shown to be particularly beneficial in assessing shoulder physeal injuries in pediatric patients 1, 4
  • Nondisplaced fractures: Greater tuberosity, humeral head, or lateral clavicle fractures that are radiographically occult 2
  • Bone marrow contusions/edema: Indicative of significant trauma even without visible fracture 1, 2

Other Considerations

  • Acromioclavicular sprains: May not be apparent on standard radiographs 2
  • Muscle strains or partial detachments: Including pectoralis major or coracobrachialis 2

Clinical Reasoning

The inability to use the arm is a critical finding. Research demonstrates that patients unable to actively abduct to 90° at presentation and at two-week follow-up have significant soft tissue pathology in the majority of cases, despite normal radiographs 3. In one prospective study, only 1 of 20 patients with this presentation had truly normal findings on advanced imaging 3.

A study specifically examining pediatric shoulder trauma with normal x-rays found that MRI revealed abnormalities in 41 of 48 patients (85%), establishing definitive diagnoses including rotator cuff tears (13 cases), fractures (6 cases), instability (4 cases), and acromioclavicular sprains (8 cases) 2.

Recommended Next Steps

Immediate Advanced Imaging

MRI shoulder without IV contrast is the most appropriate next imaging study 1. The 2025 ACR Appropriateness Criteria specifically state that in acute shoulder pain with normal radiographs and suspicion for occult injury, MRI without contrast is usually appropriate 1.

Key advantages of MRI in this scenario:

  • Demonstrates bone marrow edema indicating occult fractures 1
  • Identifies capsuloligamentous soft tissue pathology including rotator cuff and labral tears 1
  • Particularly beneficial for assessing shoulder physeal injuries in pediatric patients 1, 4
  • In acute trauma, joint effusion provides natural contrast for intra-articular structures, making IV contrast unnecessary 1
  • Superior to CT for soft tissue evaluation 4

Alternative: CT Without Contrast

CT without IV contrast may be considered if MRI is unavailable or contraindicated 1. However, CT is inferior for soft tissue injuries and should be reserved primarily for detailed osseous evaluation 1.

Ultrasound Limitations

While ultrasound can detect rotator cuff tears, it has significant limitations in this scenario 1, 2:

  • Completely overlooks shoulder instability (0% detection rate) 2
  • Misses bone contusions and physeal injuries
  • Limited for non-localized shoulder pain 4
  • Operator-dependent with high variability

Common Pitfalls to Avoid

  1. Assuming normal radiographs exclude significant injury: Up to 85% of patients with acute shoulder trauma and normal x-rays have significant pathology on MRI 2

  2. Relying on initial clinical examination alone: Concordance with final diagnosis is only 42% on initial examination and 52% on reassessment, due to pain limiting examination 2

  3. Delaying advanced imaging in children unable to use the arm: This presentation indicates significant injury requiring definitive diagnosis 3

  4. Ordering ultrasound as the primary advanced imaging: US has only 71% concordance with final diagnosis and completely misses instability 2

  5. Missing physeal injuries: These are unique to pediatric patients and require MRI for detection 1, 4

References

1
Guideline

acr appropriateness criteria® acute shoulder pain: 2024 update.

Journal of the American College of Radiology, 2025

4
Guideline

acr appropriateness criteria<sup>®</sup> shoulder pain-traumatic.

Journal of the American College of Radiology, 2018

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This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.