Comprehensive Approach to Shoulder Pain Evaluation
The evaluation of shoulder pain should begin with plain radiographs including anteroposterior, external rotation, and axillary or scapular Y views, followed by MRI without contrast if symptoms persist despite normal radiographs. 1
Initial Assessment
History
- Mechanism of injury: traumatic vs. gradual onset
- Pain characteristics: location, radiation, aggravating/alleviating factors
- Functional limitations: overhead activities, sleep disturbance, daily activities
- Associated symptoms: catching, clicking, instability, limited range of motion
- Previous treatments and their effectiveness
Physical Examination
- Inspection: muscle atrophy, asymmetry, deformity
- Palpation: identify tender areas (acromioclavicular joint, bicipital groove, subacromial space)
- Range of motion: active and passive
- Special tests:
- Impingement tests: Neer's test (88.7% sensitivity, 33% specificity), Hawkins test
- Rotator cuff integrity: Empty can test, external rotation resistance test
- Labral pathology: O'Brien's test, anterior apprehension test
- AC joint: cross-body adduction test
Clinical Pearl: Combining multiple impingement tests significantly improves diagnostic accuracy for subacromial impingement syndrome 1
Imaging Algorithm
First-line imaging: Plain radiographs with at least 3 views
- Anteroposterior (AP) view
- External rotation view
- Axillary or scapular Y view
Second-line imaging (if radiographs are noncontributory but symptoms persist):
- MRI without contrast for soft tissue pathology evaluation
- MR arthrography for suspected labral tears (gold standard with 86-100% sensitivity)
- CT arthrography if MRI is contraindicated
Important: Ultrasound has limited role in diagnosing labral tears but can be useful for evaluating rotator cuff and biceps tendon pathology 1
Diagnostic Approach by Common Pathologies
Rotator Cuff Disorders
- Look for pain with overhead activities, night pain, and weakness
- Positive impingement signs (Neer's, Hawkins)
- Weakness in specific muscle testing (supraspinatus, infraspinatus)
- MRI is preferred for definitive diagnosis
Labral Tears
- Symptoms include pain, catching/clicking, instability
- Often difficult to diagnose clinically, especially anterosuperior tears
- MR arthrography is the gold standard for diagnosis
- Consider in younger patients with instability or athletes with overhead activities
Acromioclavicular Joint Arthritis
- Localized pain at AC joint
- Positive cross-body adduction test
- Pain with direct palpation of AC joint
- Radiographs may show joint space narrowing or osteophytes
Glenohumeral Arthritis
- Progressive pain and stiffness
- Decreased range of motion in multiple planes
- Crepitus with movement
- Radiographs show joint space narrowing, subchondral sclerosis, osteophytes
Management Considerations
Initial treatment for most shoulder conditions should be conservative:
- NSAIDs as first-line medication for pain management
- Physical therapy with appropriate exercises based on diagnosis
- Activity modification
Consider corticosteroid injections for significant pain, but limit to 3-4 per year to avoid tendon weakening 1
Surgical referral criteria:
- Age under 30 years
- Participation in high-demand or contact sports
- Evidence of significant Hill-Sachs lesion or Bankart tear
- No improvement after 3 months of appropriate rehabilitation
Follow-up Schedule
- Initial follow-up: 1-2 weeks after treatment initiation
- Clinical reassessment: 6 weeks to evaluate progress
- Rehabilitation progress evaluation: 3 months
- Consider repeat imaging or surgical consultation if symptoms worsen or don't improve by 3 months 1
Caution: Isolated anterosuperior labral tears are often missed clinically, highlighting the importance of appropriate imaging when symptoms persist despite treatment 1