What is the approach to evaluating shoulder pain?

Evaluation of Shoulder Pain

Radiography should be the initial imaging modality for all patients with shoulder pain, with at least three views including anteroposterior (AP), axillary lateral, and scapular Y views to assess for fractures and malalignment. 1

Initial Assessment

History

• Mechanism of injury (traumatic vs. non-traumatic)
• Duration of symptoms (acute < 2 weeks vs. chronic)
• Location and radiation of pain
• Aggravating/relieving factors
• Previous shoulder injuries or surgeries
• Activities that provoke symptoms (overhead activities, throwing)
• Associated symptoms (instability, weakness, limited range of motion)

Physical Examination

1. Inspection:

   • Muscle atrophy
   • Deformity
   • Swelling
   • Scapular winging

2. Palpation:

   • Tenderness over specific structures (acromioclavicular joint, bicipital groove, rotator cuff insertion)
   • Muscle trigger points, particularly in teres major 2

3. Range of Motion Assessment:

   • Active and passive motion in all planes
   • Note any painful arcs of motion
   • Assess for capsular patterns (limitation in specific directions)

4. Special Tests:

   • Rotator cuff: Empty can test, Hawkins-Kennedy, Neer impingement
   • Instability: Apprehension test, relocation test
   • Labral tears: O'Brien's test, crank test
   • Biceps: Speed's test, Yergason's test
   • AC joint: Cross-body adduction test

Imaging Algorithm

Step 1: Radiography

• Standard radiographs for all patients with shoulder pain 1
• Include AP views (internal and external rotation), axillary lateral view, and scapular Y view
• Radiographs should be performed upright when possible 1
• Special views may be indicated:
  • Rockwood view or suprascapular outlet view for impingement
  • Westpoint view for bony Bankart lesions
  • Stryker notch view for Hill-Sachs deformities 1

Step 2: Advanced Imaging (if radiographs are noncontributory)

For patients < 35 years with suspected labral tear or instability:

• MR arthrography is the preferred modality (rated 9/9) 1
• MRI without contrast is an alternative (rated 7/9) 1
• CT arthrography if MRI is contraindicated (rated 5/9) 1

For patients with suspected rotator cuff pathology:

• MRI without contrast is preferred
• Ultrasound is an alternative if performed by experienced operators
• MR arthrography for partial-thickness tears or post-surgical evaluation 1

For suspected septic arthritis:

• Ultrasound or fluoroscopy-guided arthrocentesis is the procedure of choice (rated 9/9) 1
• MRI with contrast if aspiration is not possible (rated 7/9) 1

For trauma evaluation:

• CT for better characterization of complex fractures 1
• MRI for associated soft tissue injuries 1

Management Based on Diagnosis

1. Fractures and Dislocations:

   • Unstable or significantly displaced fractures require urgent surgical referral 1
   • Stable fractures can be managed conservatively

2. Rotator Cuff Disorders:

   • Initial conservative management with physical therapy
   • Consider corticosteroid injections for persistent pain
   • Surgical referral for full-thickness tears or failed conservative treatment

3. Labral Tears:

   • Conservative management for 6-12 weeks
   • Surgical referral for persistent symptoms or significant instability

4. Glenohumeral Arthritis:

   • Conservative management with activity modification, NSAIDs, and physical therapy
   • Consider corticosteroid injections
   • Surgical referral for advanced disease

5. Inflammatory Conditions:

   • Anti-inflammatory medications
   • Physical therapy for range of motion
   • Disease-modifying agents for rheumatologic conditions

Common Pitfalls to Avoid

1. Failure to obtain orthogonal views on radiography, potentially missing dislocations or fractures 1

2. Overlooking referred pain from cervical spine or visceral sources

3. Inadequate physical examination - ensure comprehensive testing of all shoulder structures

4. Premature advanced imaging before appropriate radiographs

5. Delayed diagnosis of septic arthritis - maintain high suspicion and low threshold for arthrocentesis when clinically indicated 1

6. Missing associated injuries in traumatic cases - evaluate for concomitant labral tears with rotator cuff injuries

By following this structured approach to evaluating shoulder pain, clinicians can efficiently reach an accurate diagnosis and implement appropriate management strategies to improve outcomes related to morbidity, mortality, and quality of life.