Initial Assessment and Treatment for Right Shoulder Pain
The initial assessment for right shoulder pain should include radiography as the mainstay imaging modality, followed by appropriate physical examination tests, with treatment beginning with NSAIDs and supervised physical therapy. 1, 2
Diagnostic Assessment
Initial Imaging
- Plain radiographs should be the first-line imaging for all shoulder pain 1, 2
- Include AP, Grashey, axillary, and/or scapular Y projections
- Special projections when indicated:
- Rockwood view for impingement
- Westpoint view for Bankart fractures
- Stryker notch view for Hill-Sachs fractures
Physical Examination
- Perform targeted examination including:
- Inspection for asymmetry, muscle atrophy, or deformity
- Palpation of key structures (acromioclavicular joint, biceps tendon, rotator cuff)
- Range of motion assessment in all planes
- Special tests:
- Speed's test (sensitivity 32%, specificity 75%) for biceps pathology
- Yergason's test (sensitivity 43%, specificity 79%) for biceps instability
- Tests for impingement and rotator cuff integrity 2
Advanced Imaging (if needed based on initial findings)
- MRI without contrast (rated 7/9 for appropriateness) for suspected soft tissue injuries 1, 2
- MR arthrography particularly valuable for patients under 35 years with suspected labral pathology 1, 2
- Ultrasound can evaluate rotator cuff tendons and biceps tendon with appropriate expertise 1
- CT useful for characterizing complex fractures if radiographs are inconclusive 1
Important caveat: If septic arthritis is suspected, ultrasound or x-ray guided arthrocentesis is the procedure of choice (both rated 9/9 for appropriateness) 1
Treatment Approach
First-Line Treatment
Pain management:
Physical therapy (supervised shows better outcomes than home exercises alone) 2:
- Active and passive range of motion exercises
- Rotator cuff strengthening exercises
- Scapular stabilization exercises
- Manual therapy techniques
Second-Line Treatment
Corticosteroid injections for specific conditions 2, 4:
- Subacromial bursitis
- Adhesive capsulitis
- Calcific tendinopathy
Specialized techniques based on diagnosis 2, 4:
- Hydrodilatation for adhesive capsulitis
- Barbotage for calcific tendinitis
- Extracorporeal shock wave therapy for calcific tendinitis
Important pitfall: Avoid injecting lidocaine or high concentrations of long-acting local anesthetics into joints due to chondrotoxicity 4
Surgical Referral Considerations
Consider surgical consultation if:
- Patient is under 30 years with instability
- Participates in high-demand or contact sports
- Evidence of significant Hill-Sachs lesion or Bankart tear
- Failed conservative management after 3-6 months 2
Condition-Specific Approaches
Rotator Cuff Pathology (most common cause, >2/3 of cases) 3
- Begin with NSAIDs and supervised PT focusing on rotator cuff strengthening
- Consider subacromial corticosteroid injection if not improving
- MRI without contrast if suspecting tear
Adhesive Capsulitis
- Focus on gentle stretching and mobilization techniques
- Consider corticosteroid injection or hydrodilatation
- Emphasize gradual increase in external rotation and abduction 2
Biceps Tendinopathy
- NSAIDs and targeted strengthening
- Avoid aggravating activities
- Consider ultrasound-guided injection if not improving 2
Suspected Septic Arthritis
- Immediate arthrocentesis for diagnosis and treatment
- Urgent orthopedic consultation
- Empiric antibiotics after obtaining cultures 1
Follow-Up Recommendations
- Initial follow-up at 1-2 weeks to assess response to treatment
- Clinical reassessment at 6 weeks
- Evaluation for progress of rehabilitation at 3 months
- Consider advanced imaging or specialist referral if not improving with conservative measures 2