Initial Evaluation and Management of Shoulder Pain
The initial evaluation of a patient with shoulder pain should begin with radiography, which is the preferred initial diagnostic modality as it can effectively delineate shoulder malalignment and most shoulder fractures. 1
Clinical Assessment
- A thorough clinical history should focus on mechanism of injury, as traumatic shoulder pain can be directly attributed to acute or chronic traumatic events 1
- Determine if the pain is traumatic (fractures, dislocations) or non-traumatic (rotator cuff disorders, inflammatory conditions) in nature 1
- Assess for red flags that may require urgent referral, including significant trauma, joint instability, or neurological symptoms 1
Initial Imaging
Radiography
- Standard radiographic evaluation should include at minimum three views 1:
- Anteroposterior (AP) views in internal and external rotation
- Axillary or scapula-Y view (vital for evaluating dislocations that may be missed on AP views)
- Radiographs should be performed upright, as shoulder malalignment can be underrepresented on supine radiography 1
- The Stryker notch view can be used to evaluate Hill-Sachs lesions 1
When to Consider Advanced Imaging
- CT is better for characterizing complex fracture patterns when radiographs are indeterminate 1
- MRI (non-contrast) is effective for diagnosing soft-tissue pathologies including labral, rotator cuff, and glenohumeral ligament injuries 1
- MR arthrography is considered the gold standard for traumatic shoulder pain but is not recommended as an initial study due to its invasive nature 1
- Ultrasound has limited usefulness in initial evaluation but is comparable to MRI for evaluating full-thickness rotator cuff tears 1
Management Approach
Initial Management
- Separate injuries into two categories 1:
- Those requiring acute surgical management (unstable/displaced fractures, joint instability)
- Those appropriate for initial conservative management (most soft-tissue injuries)
Conservative Management
- For non-surgical cases, begin with activity modification and analgesics 1
- If there are no contraindications, acetaminophen or ibuprofen can be used for pain relief 1
- For shoulder pain related to limitations in range of motion, implement gentle stretching and mobilization techniques 1
- Active range of motion should be increased gradually while restoring alignment and strengthening weak muscles in the shoulder girdle 1
Injection Therapy
- Subacromial corticosteroid injections can be used when pain is related to injury or inflammation of the subacromial region (rotator cuff or bursa) 1
- For pain related to spasticity, botulinum toxin injections into the subscapularis and pectoralis muscles may be considered 1
When to Refer
- Refer patients with unstable or significantly displaced fractures and joint instability for surgical evaluation 1
- Consider referral if symptoms persist or worsen after 6-12 weeks of directed treatment 2
- Traumatic massive rotator cuff tears may require expedited surgical referral for optimal functional outcomes 1
Special Considerations
- Patient factors such as age, comorbidities, and expected activity level help determine appropriate management strategy 1
- For Complex Regional Pain Syndrome (CRPS) following shoulder injury, consider an early course of oral corticosteroids (30-50 mg daily for 3-5 days, then tapering over 1-2 weeks) 1
- Adaptive devices may be considered if other methods of performing specific functional tasks are not available 1
Common Pitfalls to Avoid
- Failure to obtain axillary or scapula-Y views can lead to missed diagnoses of acromioclavicular and glenohumeral dislocations 1
- Relying solely on AP views for diagnosis can result in misclassification of shoulder injuries 1
- Delaying treatment of traumatic massive rotator cuff tears may lead to suboptimal functional outcomes 1
- Treating based on imaging findings alone without clinical correlation may lead to inappropriate interventions, as imaging abnormalities are not always symptomatic 3