What is the initial assessment and management plan for a patient presenting with shoulder pain?

Initial Assessment and Management of Shoulder Pain

The initial assessment of shoulder pain should include a structured history and physical examination, followed by plain radiography as the first imaging modality, with conservative management as first-line treatment including NSAIDs, activity modification, and a phased rehabilitation approach. 1

Initial Assessment

History

• Onset: Acute (trauma) vs. gradual onset
• Location: Anterior, posterior, lateral, or diffuse
• Quality: Sharp, dull, aching
• Radiation: Down arm, to neck
• Aggravating factors: Overhead activities, specific movements
• Alleviating factors: Rest, medications
• Associated symptoms: Weakness, instability, clicking/popping
• Previous treatments and their effectiveness

Physical Examination

1. Inspection:

   • Muscle atrophy
   • Swelling
   • Deformity
   • Scapular winging

2. Palpation:

   • Acromioclavicular joint
   • Bicipital groove
   • Greater tuberosity
   • Subacromial space

3. Range of Motion:

   • Active and passive
   • Forward flexion, abduction, external/internal rotation
   • Compare to contralateral side

4. Special Tests:

   • Rotator cuff: Neer's test, Hawkins test, empty can test
   • Labral tears: O'Brien's test, anterior apprehension test
   • Biceps: Speed's test, Yergason's test
   • AC joint: Cross-body adduction test

5. Neurovascular Examination:

   • Sensory and motor examination of upper extremity
   • Neck examination to rule out cervical pathology

Imaging

1. Plain Radiography:

   • Should be the initial imaging modality for chronic shoulder injuries 1
   • Standard views: AP, lateral, axillary
   • Evaluate for fractures, dislocations, arthritis, calcifications

2. Advanced Imaging (if radiographs negative and symptoms persist):

   • MRI without contrast: Preferred for rotator cuff tears, non-localized shoulder pain, and suspected labral tears 1
   • Ultrasound: Equivalent alternative to MRI for rotator cuff tears depending on local expertise 1
   • MR Arthrography: Gold standard for labral tears, especially in patients under 35 1

Management Plan

First-Line Treatment

1. Pain Management:

   • NSAIDs: Recommended for pain control 1
   • Acetaminophen: Alternative if NSAIDs contraindicated
   • Local thermal interventions: Heat or cold for symptomatic relief 1

2. Activity Modification:

   • Avoid painful movements 1
   • Proper positioning education

3. Rehabilitation (Phased Approach):

   • Phase 1: Pain control, gentle range of motion exercises 1
   • Phase 2: Progressive ROM exercises, light strengthening for rotator cuff and periscapular muscles 1
   • Phase 3: Progressive resistance training, advanced scapular stabilization, and activity-specific training 1

Second-Line Treatment

1. Corticosteroid Injections:
   • May provide short-term improvement
   • Should be limited (no more than 3-4 per year) to avoid tendon weakening 1
   • Consider potential adverse effects on tendon biology and healing capacity

Surgical Considerations

• Consider surgical consultation if:
  • No improvement after 3 months of appropriate rehabilitation
  • Patient under 30 years with high athletic demands
  • Evidence of significant mechanical symptoms 1
  • Acute traumatic injuries with structural damage

Follow-up and Monitoring

1. Initial follow-up: 1-2 weeks after treatment initiation 1
2. Clinical reassessment: At 6 weeks to evaluate progress 1
3. Rehabilitation progress evaluation: At 3 months 1
4. Consider imaging or surgical consultation: If symptoms worsen or do not improve by 3 months 1

Common Pitfalls and Caveats

• Don't miss red flags: Acute trauma, significant weakness, or mass requires urgent referral 2
• Normal X-rays don't rule out pathology: Soft tissue injuries like rotator cuff tears, labral tears, and bursitis may not be visible on plain films 1
• Avoid overtreatment: Surgery is not recommended for asymptomatic full-thickness rotator cuff tears, even if detected on imaging 1
• Consider referred pain: Always examine the neck to rule out cervical pathology as a source of shoulder pain 3
• Treat the patient, not the images: Imaging abnormalities may not correlate with symptoms 4