From the Guidelines
The next step in evaluating a patient with shoulder pain is to perform a comprehensive clinical assessment, including a detailed history and physical examination. This assessment should begin by asking about the pain's onset, duration, location, quality, and aggravating or alleviating factors, as well as inquiring about any trauma, repetitive activities, or previous shoulder problems 1. The physical examination should include inspection for deformity or muscle atrophy, palpation for tenderness, assessment of active and passive range of motion, and specific provocative tests such as the Neer impingement test, Hawkins-Kennedy test, empty can test, and O'Brien's test.
Based on these findings, appropriate imaging may be ordered, typically starting with plain radiographs (anteroposterior, axillary lateral, and scapular Y views) to evaluate for fractures, dislocations, arthritis, or calcifications. If soft tissue pathology is suspected, further imaging such as ultrasound or MRI may be warranted, with both options being equivalent in evaluation, according to the American College of Radiology 1. This systematic approach helps differentiate between common causes of shoulder pain including rotator cuff disorders, adhesive capsulitis, osteoarthritis, instability, and referred pain from cervical spine or visceral sources, allowing for targeted treatment planning. Key considerations include:
- Detailed history to identify potential causes and contributing factors
- Comprehensive physical examination to assess range of motion, strength, and tenderness
- Imaging studies, starting with plain radiographs and potentially including ultrasound or MRI for soft tissue evaluation
- Consideration of various potential diagnoses, including rotator cuff disorders, adhesive capsulitis, and osteoarthritis, to guide treatment planning.
From the Research
Next Steps in Evaluating a Patient with Shoulder Pain
The evaluation of a patient with shoulder pain involves a step-by-step approach to determine the underlying cause of the pain.
- Obtaining an accurate history and physical examination are the first steps in evaluating shoulder pain, as noted in 2.
- Conventional radiography is also an initial step, with the use of other imaging modalities such as ultrasound, magnetic resonance imaging (MRI), and computed tomography (CT) based on the type of additional information needed 2.
- A structured assessment that includes taking the patient's history and performing clinical assessment procedures is crucial in diagnosing rotator cuff tendinopathy or subacromial impingement syndrome 3.
- The clinical diagnosis can be strengthened with the findings from supporting investigations such as blood tests, radiographs, ultrasound, MRI, CT, and diagnostic analgesic injection 3.
Diagnostic Considerations
- Subacromial impingement/pain syndrome is a common cause of shoulder pain that encompasses a spectrum of pathology of the subacromial bursa and rotator cuff tendons 4.
- MRI and ultrasonography may be useful to evaluate for soft tissue pathology, depending on the level of clinical concern regarding rotator cuff tear 4.
- A standardized approach to the clinical assessment of a musculoskeletal problem is necessary, whether the patient is presenting to primary care, rheumatology, or orthopedics 5.
Imaging and Treatment
- MRI features such as high signal intensities on T1 and T2 weighted images, and fluid-fluid level on T2 weighted images can be useful for the diagnosis of scapulothoracic bursitis 6.
- Conservative treatment can be successful for scapulothoracic bursitis, and surgery is not necessary except for cases with pain, excessive friction, or dysfunction 6.