What is the appropriate workup for a patient presenting with right shoulder pain?

Appropriate Workup for Right Shoulder Pain

The appropriate workup for right shoulder pain should begin with standard radiographs (AP views in internal and external rotation, and axillary or scapula-Y view) as the initial diagnostic modality to evaluate for fractures, dislocations, and shoulder alignment. 1

Initial Clinical Assessment

• History elements to focus on:

  • Onset (acute vs. gradual)
  • Location (anterior, posterior, lateral)
  • Pain characteristics (during movement, at rest, at night)
  • Mechanism of injury (if applicable)
  • Previous shoulder problems
  • Activity limitations
  • Associated symptoms (weakness, numbness, instability)

• Physical examination components:

  • Inspection for deformity, muscle atrophy, or asymmetry
  • Palpation for tenderness
  • Range of motion assessment (active and passive)
  • Strength testing of rotator cuff muscles
  • Special tests:
    • Impingement tests (Neer, Hawkins-Kennedy)
    • Rotator cuff integrity tests (empty can, drop arm)
    • Instability tests (apprehension, relocation)
    • AC joint assessment (cross-body adduction)
    • Biceps tests (Speed's, Yergason's)

Diagnostic Imaging Algorithm

1. Standard radiographs (first-line imaging):

   • AP views in internal and external rotation
   • Axillary or scapula-Y view
   • Purpose: Evaluate for fractures, dislocations, and shoulder alignment 1
   • Note: Normal X-rays do not rule out soft tissue pathology 1

2. If radiographs are normal but symptoms persist:

   • MRI (preferred for soft tissue pathology):
     • Standard MRI without contrast is highly effective (rated 7/9) 1
     • MR Arthrography is the gold standard for labral tears (sensitivity 86-100%), especially in patients under 35 1

3. Alternative imaging options:

   • CT Arthrography: Third choice, only if MRI is contraindicated 1
   • Ultrasound: Can evaluate rotator cuff and biceps tendon pathology but inferior to MRI 1

Treatment Considerations Based on Diagnosis

• For impingement/bursitis/tendinitis:

  • NSAIDs as first-line medication (taper as tolerated) 1
  • Local cold therapy for pain relief 1
  • Exercise therapy focusing on rotator cuff and periscapular muscle strengthening 1
  • Consider corticosteroid injection if significant pain (limit to 3-4 per year) 1

• For suspected rotator cuff tears:

  • MRI or arthrography to confirm diagnosis 1, 2
  • Refer to orthopedist for surgical evaluation if confirmed 3

Follow-up Protocol

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

Indications for Specialist Referral

• No improvement after 3 months of appropriate rehabilitation 1, 3
• Patient under 30 years with high athletic demands 1
• Evidence of significant mechanical symptoms 1
• Acute injuries or "red flag" diagnoses (urgent referral) 3
• Significant Hill-Sachs lesion or Bankart tear on imaging 1

Common Pitfalls to Avoid

• Relying solely on imaging findings without clinical correlation - treat the patient, not the images 4
• Missing rare causes of shoulder pain like Parsonage-Turner syndrome, which presents with acute onset shoulder pain, myalgia, and sensory disturbances 5
• Overuse of corticosteroid injections (limit to 3-4 per year) to avoid tendon weakening 1
• Injecting steroids directly into tendons (contraindicated) 2
• Failing to consider multiple concurrent shoulder pathologies 4

Remember that many patients with chronic shoulder pain can be successfully treated non-surgically with appropriate rehabilitation protocols 3, but those who fail conservative management should be referred for surgical consultation.