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

Initial Management of Shoulder Pain

The initial management for a patient presenting with shoulder pain should begin with radiographic evaluation including at least three views: anteroposterior (AP) views in internal and external rotation, and an axillary or scapula-Y view to properly assess for potential fractures, dislocations, or other structural abnormalities. 1, 2

Clinical Assessment

• Obtain a thorough clinical history focusing on the mechanism of injury, as shoulder pain can be categorized as traumatic (fractures, dislocations) or non-traumatic (rotator cuff disorders, inflammatory conditions) 2
• Assess for red flags requiring urgent referral, including significant trauma, joint instability, or neurological symptoms 2
• Determine if pain is sharp/burning (potentially radicular in origin) or dull/diffuse/aching (often tendinitis-related) 3
• Evaluate range of motion and ability to perform daily activities to gauge functional impairment 4

Initial Imaging Approach

• Standard radiography is the preferred initial diagnostic modality for acute shoulder pain 1
• Radiographic shoulder studies should include:
  • Anteroposterior (AP) views with the humerus in neutral position and in internal or external rotation 1, 2
  • Axillary lateral view or scapular Y view (especially important if instability or dislocation is suspected) 1, 2
• Radiographs should be performed upright when possible, as shoulder malalignment can be underrepresented on supine radiography 2
• Failure to obtain axillary or scapula-Y views can lead to missed diagnoses of acromioclavicular and glenohumeral dislocations 2

Initial Treatment Categorization

• Separate injuries into two categories based on imaging and clinical findings 1, 2:
  • Injuries requiring acute surgical management: unstable/displaced fractures, joint instability
  • Injuries appropriate for initial conservative management: most soft-tissue injuries

Conservative Management

• For non-surgical conditions, initial treatment should include 3, 5:
  • Short course of rest and ice
  • Topical analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs)
  • Directed and supervised physical therapy
  • Subacromial corticosteroid injections may be considered in appropriate cases

Surgical Referral Indications

• Refer patients with the following conditions for surgical evaluation 1, 2:
  • Unstable or significantly displaced fractures
  • Joint instability
  • Traumatic massive rotator cuff tears (require expedited referral for optimal functional outcomes)
  • Failure to improve with appropriate conservative management

Special Considerations

• Patient factors such as age, comorbidities, and expected activity level help determine the appropriate management strategy 1, 2
• Most causes of shoulder pain can be adequately treated non-surgically with physiotherapy, anti-inflammatory medication, and local corticosteroid injections 4
• Delaying treatment of traumatic massive rotator cuff tears may lead to suboptimal functional outcomes 2