In a 67-year-old patient with left shoulder pain and a popping sensation, what is the appropriate evaluation and management?

Initial Management: Start with Plain Radiographs

For a 67-year-old with left shoulder pain and popping sensation, you should immediately order plain radiographs of the shoulder as your first imaging study, then perform a focused physical examination to differentiate between rotator cuff pathology, labral injury, or instability 1.

Immediate Diagnostic Approach

Step 1: Order Shoulder Radiographs First

Plain radiography is the appropriate initial imaging for acute shoulder pain of any etiology 1. This rules out fractures, dislocations, and significant bony pathology before proceeding further.

Step 2: Focused Physical Examination

While awaiting imaging, perform these specific maneuvers:

For Rotator Cuff Tears (most likely in this age group):

• Empty can test (supraspinatus)
• External rotation lag sign
• Lift-off test (subscapularis)
• Belly press test
• Look for muscle atrophy or visible deformity 2

For Impingement:

• Neer's sign
• Hawkins' sign 2

For Instability/Labral Pathology:

• Assess for apprehension with external rotation
• Note any history of dislocation

Critical Context: At age 67, this patient has a 31% prevalence of rotator cuff tears even if asymptomatic 3. The "popping" sensation has limited diagnostic value for identifying acute tendon rupture—it is NOT reliably associated with acute rotator cuff defects 4. Most shoulder pain in this age group represents degenerative pathology, not acute injury.

Next Steps Based on Radiograph Results

If Radiographs Are Normal or Nonspecific:

For suspected rotator cuff tear (most common at this age):

• Order MRI shoulder without IV contrast OR ultrasound 1
• Both have equivalent 90-91% sensitivity and 93-95% specificity for full-thickness tears 1
• Choose MRI if: large body habitus, restricted range of motion from pain, or suspicion of other pathology like labral tears 1
• Choose ultrasound if: cost is a concern, faster access, or patient has contraindications to MRI 1

For suspected labral tear or instability:

• Order MRI shoulder without IV contrast 1
• In acute settings, post-traumatic effusion provides natural contrast—MR arthrography is unnecessary 1

If Radiographs Show Fracture:

• Order CT shoulder without IV contrast for surgical planning 1
• Consider MRI only if assessing rotator cuff injury in patients NOT planned for surgical fixation 1

If Radiographs Show Dislocation:

• Order MRI shoulder without IV contrast to evaluate soft tissue injury 1

Common Pitfalls to Avoid

1. Don't assume the "pop" means acute injury: Research shows no association between feeling a pop and actual acute rotator cuff rupture 4. Most pathology at this age is degenerative 3.

2. Don't skip radiographs: Even with obvious clinical findings, plain films are the mandatory first step 1.

3. Don't order MRI with and without contrast: There is no evidence supporting this for rotator cuff evaluation 1.

4. Don't delay imaging if red flags present: Rule out major structural pathology early 5.

5. Don't order MR arthrography acutely: Natural joint effusion from acute injury provides adequate visualization 1.

Treatment Considerations While Awaiting Advanced Imaging

If radiographs are negative and rotator cuff pathology is suspected, you can initiate conservative management:

• Low-level laser therapy
• Multimodal care (heat/cold, joint mobilization, range of motion exercises)
• Cervicothoracic manipulation if associated neck symptoms 5

Avoid: Ultrasound therapy, taping, interferential current, or soft tissue massage alone—these lack evidence 5.

Reassessment Timeline

Monitor at each visit for:

• Worsening symptoms
• New neurological findings
• Failure to improve with conservative measures
• Development of significant weakness or atrophy (suggests massive tear requiring surgical evaluation) 6

The key algorithmic decision point is the radiograph result, which then directs you to either MRI/ultrasound for soft tissue evaluation or CT for bony detail 1.