From the Guidelines
The diagnostic approach for a separated shoulder should begin with a thorough history and physical examination, followed by plain radiographs as the primary imaging modality, as recommended by the American College of Radiology 1. The physical examination should include inspection for visible deformity or step-off at the acromioclavicular joint, palpation for tenderness, and special tests such as the cross-body adduction test which reproduces pain. Some key points to consider in the diagnostic approach include:
- Patients typically present with pain at the top of the shoulder after a direct fall onto the shoulder or outstretched hand.
- Weight-bearing (stress) views with the patient holding weights in both hands can help assess joint stability and grade the severity of separation.
- The Rockwood classification system divides AC joint injuries into six types based on severity, which guides treatment decisions.
- In cases where there is uncertainty or suspicion of associated injuries, advanced imaging such as MRI may be indicated to evaluate the status of the coracoclavicular ligaments and surrounding soft tissues, as suggested by the ACR appropriateness criteria 1. The diagnostic approach should be comprehensive yet efficient to allow for appropriate treatment planning based on the grade of separation. Key imaging modalities to consider include:
- Radiography: the preferred initial study for traumatic shoulder pain, which can delineate shoulder malalignment and most shoulder fractures 1.
- MRI: may be indicated for assessment of soft-tissue injuries, such as labroligamentous complex injuries, and for evaluation of the coracoclavicular ligaments and surrounding soft tissues 1.
- Ultrasound: can be useful for dynamic assessment of the joint and for assessment of rotator cuff injuries, but has limited usefulness for assessment of the deep soft-tissues 1.
From the Research
Diagnostic Approach for a Separated Shoulder
To diagnose a separated shoulder, a thorough physical examination is essential, as the condition can have a significant impact on a patient's ability to function [(2,3)]. The diagnostic approach involves:
- History and Physical Examination: A comprehensive history and physical examination are crucial in identifying the etiology of shoulder problems [(2,4,3,5)]
- Inspection, Palpation, Range of Motion, Strength, and Neurovascular Integrity: The basic tenets of physical examination must be followed, including inspection, palpation, range of motion, strength, and neurovascular integrity 3
- Specific Exam Maneuvers: Specific exam maneuvers must be utilized to isolate and help differentiate pathologies, such as rotator cuff injury, shoulder instability, or impingement 3
- Standard and Specific Physical Examinations: A standard physical examination can prompt the examiner to focus on specific tests to further evaluate the shoulder and limit the differential diagnoses 5
Key Considerations
When diagnosing a separated shoulder, it is essential to consider the complexity of the shoulder joint and the various structures involved [(2,3)]. A thorough understanding of shoulder anatomy and biomechanics is necessary to properly identify and diagnose shoulder pathology 3. Additionally, the physical examination should be methodical and well-performed to help distinguish different etiologies of shoulder dysfunction 2.