What is the appropriate diagnostic workup and initial management for a patient presenting with right shoulder pain?

Diagnostic Workup for Right Shoulder Pain

The appropriate diagnostic workup for right shoulder pain should begin with plain radiographs including at least 3 views (anteroposterior, Grashey projection, and either axillary lateral or scapular Y view), followed by MR arthrography if labral tear is suspected or standard MRI without contrast for evaluation of rotator cuff pathology. 1, 2

Initial Evaluation

Radiographic Assessment

• Plain radiographs are the first-line imaging modality for all causes of acute shoulder pain 1
• Minimum of 3 views required for trauma evaluation:
  • Anteroposterior (AP) view with humerus in neutral position
  • Grashey projection (30° posterior oblique profile) to profile the glenohumeral joint
  • Either axillary lateral view or scapular Y view (especially important for suspected instability or dislocation)
• Caution: Axillary lateral view may be painful and potentially cause redislocation in recently reduced shoulders 1

Advanced Imaging Based on Suspected Pathology

For suspected labral tear (especially in patients under 35 years):

• MR arthrography: Gold standard (rated 9/9 for appropriateness) 1, 2
• Standard MRI without contrast: Highly effective alternative (rated 7/9) with optimized imaging equipment 1, 2
• CT arthrography: Consider only if MRI is contraindicated (rated 5/9) 1, 2

For rotator cuff pathology:

• MRI without contrast: Preferred modality 2
• Ultrasound: Limited role but can evaluate rotator cuff and biceps tendon pathology 2

Clinical Decision Algorithm

1. For acute trauma:

   • Obtain radiographs with minimum 3 views
   • Perform neurovascular assessment before any manipulation attempts 2
   • If dislocation is suspected, include axillary or scapular Y view 1

2. For suspected labral tear (especially in patients <35 years with instability):

   • Start with plain radiographs
   • Proceed to MR arthrography (first choice) or standard MRI (second choice) 1, 2
   • Consider CT arthrography only if MRI is contraindicated 2

3. For suspected rotator cuff pathology:

   • Start with plain radiographs
   • Proceed to MRI without contrast if symptoms persist despite initial treatment 2

Follow-up and Reassessment

• Initial follow-up: 1-2 weeks after treatment initiation 2
• Clinical reassessment: At 6 weeks to evaluate progress 2
• Rehabilitation progress evaluation: At 3 months 2

Common Pitfalls to Avoid

1. Inadequate radiographic views: Always include orthogonal views for trauma cases 1
2. Overreliance on imaging: Correlate clinical assessment with imaging findings, as asymptomatic abnormalities may be detected 3
3. Inappropriate positioning: Use caution with axillary views in recently reduced dislocations 1
4. Delayed specialist referral: Consider surgical consultation for patients under 30, those in high-demand sports, or with significant lesions on imaging 2
5. Missing cervical pathology: Remember to evaluate the neck as a potential source of referred shoulder pain 4

By following this structured approach to the diagnostic workup of right shoulder pain, clinicians can efficiently identify the underlying pathology and initiate appropriate management to improve outcomes related to morbidity, mortality, and quality of life.