How should I evaluate and manage a patient with a recent fall, inability to abduct the arm, and constant shoulder pain with all movement?

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Last updated: October 14, 2026 • View editorial policy

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Immediate Evaluation and Management

Start with plain radiographs of the shoulder (anteroposterior, scapular Y, and axillary views) immediately—this is the mandatory first imaging study for any acute shoulder pain after trauma, and inability to abduct the arm strongly suggests either a proximal humerus fracture or a complete rotator cuff tear 1.

Initial Clinical Assessment

Focus your physical examination on these specific findings:

  • Inability to hold the arm elevated against gravity indicates either a complete rotator cuff tear or a displaced proximal humerus fracture 2
  • Palpate for bony step-offs or crepitus along the proximal humerus and clavicle
  • Check for a palpable dimple inferior to the acromion (suggests dislocation) or abnormal contour
  • Document neurovascular status of the axillary nerve (deltoid sensation) and radial nerve immediately

The constant pain with all movement after a fall in someone unable to abduct makes fracture the primary concern, not just soft tissue injury 2.

Imaging Algorithm

Step 1: Plain Radiographs (Do This First)

Order shoulder radiographs with three views: true anteroposterior of the glenoid, scapular Y, and axillary view 1. This identifies most fractures and dislocations immediately.

Step 2: If Radiographs Show Fracture

  • CT shoulder without contrast is the next study to characterize fracture displacement, comminution, and surgical planning 1
  • This is particularly critical for proximal humerus fractures where surgical decision-making depends on fragment displacement and number of parts

Step 3: If Radiographs Are Normal or Nonspecific

You have two equally appropriate options 1:

  • MRI shoulder without contrast (preferred if you suspect rotator cuff tear based on inability to abduct—shows bone marrow edema from occult fracture AND evaluates rotator cuff)
  • CT shoulder without contrast (if MRI unavailable or contraindicated—better for subtle nondisplaced fractures)

Given the inability to abduct, MRI is the better choice here because it simultaneously evaluates for occult fracture AND complete rotator cuff tear 1.

Immediate Management Pending Imaging

  • Sling immobilization for comfort immediately 2
  • Adequate analgesia (NSAIDs plus opioids if needed for acute fracture pain)
  • No range-of-motion exercises until fracture is ruled out
  • Keep patient NPO if fracture is suspected and surgical fixation may be needed

Common Pitfalls to Avoid

  1. Don't assume it's just a rotator cuff strain in a post-fall patient—proximal humerus fractures in older adults can be minimally displaced and easily missed without proper radiographic views 2

  2. Don't skip the axillary view because the patient has pain—this is the only view that shows posterior dislocations and is essential for complete fracture assessment 1

  3. Don't order MRI first without plain films—this violates the imaging appropriateness pathway and may miss fractures that need immediate orthopedic consultation 1

  4. Point-of-care ultrasound can detect fractures if you're trained in it, but this doesn't replace standard radiographs for documentation and surgical planning 3

Disposition Decision

  • Displaced proximal humerus fractures (>1cm displacement, >45° angulation, or 3-4 part fractures): Immediate orthopedic consultation 2
  • Nondisplaced or minimally displaced fractures: Outpatient orthopedic follow-up within 3-5 days with sling immobilization 2
  • Complete rotator cuff tear (if MRI confirms and no fracture): Urgent orthopedic referral within 1-2 weeks, as acute tears have better surgical outcomes if repaired early

References

1
Guideline

acr appropriateness criteria® acute shoulder pain: 2024 update.

Journal of the American College of Radiology, 2025

2
Research

Acute Shoulder Injuries in Adults.

American family physician, 2016

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