What is the initial assessment and management approach for a patient presenting with shoulder pain?

Initial Assessment and Management of Shoulder Pain

Radiography is the preferred initial imaging modality for evaluating shoulder pain, with a standard set of views including anteroposterior (AP) views in internal and external rotation and an axillary or scapula-Y view. 1

Clinical Assessment

History

• Mechanism of injury: traumatic vs. non-traumatic onset
• Duration: acute (<2 weeks) vs. chronic
• Location and radiation of pain
• Aggravating and alleviating factors
• Previous shoulder injuries or treatments
• Functional limitations (work, sports, daily activities)
• Red flags: night pain, unexplained weight loss, fever

Physical Examination

1. Inspection:

   • Shoulder contour and symmetry
   • Muscle atrophy
   • Swelling or ecchymosis

2. Range of Motion Assessment:

   • Active and passive motion in all planes
   • Compare with contralateral side

3. Specific Tests:

   • Rotator cuff: Jobe test, external rotation lag sign, drop arm test
   • Impingement: Neer test, Hawkins-Kennedy test
   • Labral tears: O'Brien test, anterior slide test
   • Biceps pathology: Speed's test, Yergason's test
   • AC joint: cross-body adduction test

Clinical assessment has shown high sensitivity (90-96%) and specificity (92-97%) for diagnosing various shoulder pathologies when compared to arthroscopy 2.

Imaging Algorithm

Step 1: Plain Radiography

• Initial imaging of choice for all shoulder pain 1
• Standard views:
  • AP views in internal and external rotation
  • Axillary or scapula-Y view (critical for evaluating dislocations) 1
  • Consider upright positioning for better alignment assessment 1

Step 2: Advanced Imaging (if radiographs are noncontributory)

Based on suspected pathology:

1. For suspected labral tear/instability (especially in patients <35 years):

   • MR arthrography (first choice, rating 9/9) 1
   • Non-contrast MRI (second choice, rating 7/9) 1
   • CT arthrography if MRI contraindicated (rating 5/9) 1

2. For suspected rotator cuff pathology:

   • MRI without contrast
   • Ultrasound (if expertise available) - comparable to MRI for full-thickness tears 1

3. For suspected septic arthritis:

   • Ultrasound or fluoroscopic-guided arthrocentesis (both rated 9/9) 1
   • Send aspirate for cell count, culture, crystal analysis

Initial Management

Non-surgical Treatment

1. Pain Management:

   • NSAIDs for acute pain and inflammation
   • Acetaminophen as alternative
   • Avoid prolonged opioid use

2. Activity Modification:

   • Brief rest (1-2 days) for acute injuries
   • Avoid aggravating activities
   • Maintain gentle range of motion

3. Physical Therapy:

   • Progressive strengthening of rotator cuff muscles
   • Scapular stabilization exercises
   • Range of motion exercises

When to Refer

• Acute traumatic injuries with displacement or instability
• Failed conservative management after 4-6 weeks
• Red flag symptoms suggesting infection or malignancy
• Significant functional limitation affecting quality of life

Common Pitfalls to Avoid

1. Over-reliance on imaging: Clinical assessment has high diagnostic accuracy and should guide management decisions 2. Many shoulder abnormalities seen on imaging may be incidental findings.

2. Inadequate radiographic views: Failure to obtain axillary or scapula-Y views can lead to missed diagnoses of shoulder dislocations 1.

3. Premature surgical referral: Most non-traumatic shoulder pain responds to appropriate conservative management 3.

4. Neglecting patient education: Explaining the diagnosis, expected recovery timeline, and self-management strategies is crucial for patient engagement and improved outcomes 4.

5. Misdiagnosis of SLAP lesions: MRI has lower sensitivity (60%) for SLAP lesions compared to clinical assessment (90%) 2, highlighting the importance of thorough clinical examination.