What is the appropriate initial evaluation and management for a patient presenting with shoulder pain?

Initial Evaluation and Management for Shoulder Pain

Radiography is the most appropriate initial imaging study for patients presenting with shoulder pain, followed by advanced imaging based on specific clinical findings.

History Taking Components

When evaluating a patient with shoulder pain, focus on:

• Onset and mechanism of injury:

  • Traumatic vs. gradual onset
  • Direct fall or impact vs. repetitive use
  • Position of arm during injury 1

• Pain characteristics:

  • Location (anterior, posterior, lateral, diffuse)
  • Radiation pattern (down arm, to neck)
  • Timing (night pain suggests rotator cuff pathology)
  • Aggravating/relieving factors 2

• Functional limitations:

  • Overhead activities
  • Activities of daily living
  • Work or sports requirements 3

• Red flags:

  • Fever, weight loss, night sweats (infection/malignancy)
  • Neurological symptoms (numbness, weakness)
  • History of cancer
  • Severe pain unrelated to movement 4

Physical Examination Algorithm

1. Inspection:

   • Shoulder contour and symmetry
   • Muscle atrophy
   • Scapular winging
   • Skin changes

2. Range of motion assessment:

   • Active and passive ROM in all planes
   • Compare to contralateral side
   • Note painful arcs of motion 2

3. Strength testing:

   • Rotator cuff muscles (supraspinatus, infraspinatus, subscapularis)
   • Deltoid
   • Biceps 1

4. Special tests based on suspected pathology:

   • Impingement: Neer and Hawkins tests
   • Rotator cuff tears: Empty can test, external rotation lag sign
   • Labral tears: O'Brien's test, anterior slide test
   • Instability: Apprehension test, load and shift test
   • AC joint: Cross-body adduction test 2, 4

Diagnostic Imaging

1. Initial imaging:

   • Radiographs should be the first imaging study for all shoulder pain 1
   • Standard radiographic series should include:
     • AP views in internal and external rotation
     • Axillary or scapular Y view 1

2. Advanced imaging (based on clinical suspicion):

   • Suspected rotator cuff tear: MRI without contrast (rating 9/9) 1
   • Suspected labral tear in patient <35 years: MR arthrography (rating 9/9) 1
   • Suspected bursitis or biceps tenosynovitis: MRI without contrast 1
   • Suspected fracture with negative radiographs: CT without contrast 1
   • Suspected instability with normal radiographs: MRI without contrast or MR arthrography 1

Initial Management Approach

1. Acute traumatic injury:

   • Unstable or significantly displaced fractures require urgent surgical referral
   • Shoulder dislocations require prompt reduction and appropriate follow-up 1

2. Non-traumatic or chronic pain:

   • Initial conservative management:
     • Activity modification
     • NSAIDs for pain control
     • Physical therapy focused on appropriate exercises 3

3. Specific conditions:

   • Rotator cuff tendinopathy: Activity modification, NSAIDs, physical therapy
   • Adhesive capsulitis: Early range of motion exercises, consider corticosteroid injection
   • AC joint arthritis: Activity modification, NSAIDs, consider corticosteroid injection 2

Indications for Specialist Referral

• Failure to improve after 4-6 weeks of appropriate conservative management
• Suspected full-thickness rotator cuff tear
• Recurrent instability
• Significant loss of function despite conservative care
• Red flag symptoms suggesting infection or malignancy 3

Common Pitfalls to Avoid

• Relying solely on clinical tests for diagnosis (poor specificity)
• Overreliance on imaging findings without clinical correlation
• Failure to consider referred pain from cervical spine or internal organs
• Neglecting psychosocial factors that may contribute to chronic pain 5
• Ordering advanced imaging before appropriate radiographs 1

By following this structured approach to evaluation and management, clinicians can effectively diagnose and treat most shoulder pain presentations, leading to improved outcomes for patients.