What is the appropriate approach to evaluating and managing a patient with shoulder complaints?

Comprehensive Approach to Shoulder Evaluation and Management

The appropriate approach to evaluating and managing shoulder complaints requires a structured examination focusing on specific physical tests, appropriate imaging, and a phased rehabilitation protocol, with surgical consultation considered for patients with recurrent dislocations or lack of improvement after 3 months of therapy. 1

Initial Assessment

Physical Examination

• Standard radiographs should be obtained first, including:

  • Anteroposterior views in internal and external rotation
  • Axillary or scapula-Y view 1

• Key physical tests to perform:

  1. Range of motion assessment - evaluate for restrictions in all planes
  2. Rotator cuff strength testing
  3. Scapular assessment for winging or dyskinesia 2, 1
  4. Three critical shoulder tests:
     • Shoulder abduction
     • Shoulder external rotation
     • Horizontal shoulder adduction 3

Special Considerations by Patient Population

• Breast cancer patients: Assess for shoulder ROM restriction, strength, impingement signs, and scapular mobility 2
• Head and neck cancer patients: Examine for cervical and shoulder ROM restriction, screen for shoulder impingement and scapular winging 2
• Adolescents with recurrent dislocations: Refer directly to orthopedic surgeon without first obtaining MRI 1

Advanced Imaging

When standard radiographs are normal but symptoms persist:

• MRI without contrast is highly effective for suspected rotator cuff injury 1
• MR Arthrography is the gold standard for labral tears (86-100% sensitivity), especially in patients under 35 1
• CT shoulder is preferred for bone loss assessment 1
• Ultrasound has a limited role but can evaluate rotator cuff and biceps tendon pathology 1

Caution: Normal X-ray findings do not rule out soft tissue pathology such as rotator cuff tears, labral tears, and bursitis 1

Treatment Approach

Initial Management

1. Pain control:

   • NSAIDs as first-line medication
   • Local cold therapy
   • Temporary immobilization for comfort 1

2. Corticosteroid injections:

   • Should be limited (no more than 3-4 per year)
   • Consider only for significant pain
   • Caution: potential tendon weakening 1

Rehabilitation Protocol (Phased Approach)

Phase 1 (Initial Physical Therapy):

• Pain control measures
• Gentle range of motion exercises
• Proper positioning education
• Isometric exercises if no pain is present 1

Phase 2 (Progressive Rehabilitation):

• Progressive ROM exercises
• Light strengthening exercises for rotator cuff and periscapular muscles
• Scapular stabilization exercises 1

Phase 3 (Advanced Rehabilitation):

• Progressive resistance training
• Advanced scapular stabilization
• Sport or activity-specific training 1

Follow-up and Surgical Considerations

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

Surgical consultation should be considered if:

1. No improvement after 3 months of appropriate rehabilitation
2. Patient is under 30 years of age with high athletic demands
3. Evidence of significant mechanical symptoms
4. Patient has recurrent dislocations (especially adolescents)
5. Evidence of significant Hill-Sachs lesion or Bankart tear on imaging 1

Common Pitfalls to Avoid

1. Inadequate imaging interpretation: Remember that normal X-rays don't rule out soft tissue pathology 1
2. Missing cancer-related shoulder dysfunction: Patients with history of breast or head/neck cancer need special attention to shoulder mobility 2
3. Overuse of corticosteroid injections: Limit to 3-4 per year to prevent tendon weakening 1
4. Delayed referral: Adolescents with recurrent dislocations should be referred directly to orthopedic surgery 1
5. Inadequate physical examination: Failure to perform the three critical shoulder tests can lead to missed diagnoses 3

The shoulder is a complex joint requiring a systematic approach to diagnosis and management. By following this structured evaluation and treatment protocol, clinicians can effectively address shoulder complaints and improve patient outcomes.