Initial Management of Shoulder Pain
The initial management for a patient presenting with shoulder pain should include a thorough clinical assessment followed by appropriate radiographic imaging with at least three views (anteroposterior views in internal and external rotation, and an axillary or scapula-Y view) to guide treatment decisions. 1, 2
Clinical Assessment
- Determine if the pain is traumatic (fractures, dislocations) or non-traumatic (rotator cuff disorders, inflammatory conditions) by focusing on the mechanism of injury 2
- Assess pain characteristics - sharp or burning pain suggests radicular origin, while dull, diffuse, and aching pain often indicates tendinitis 3
- Evaluate for red flags requiring urgent referral, including significant trauma, joint instability, or neurological symptoms 2
- Categorize injuries into those requiring acute surgical management (unstable/displaced fractures, joint instability) versus those appropriate for initial conservative management (most soft tissue injuries) 1, 2
Initial Imaging
- Standard radiographic evaluation should include at minimum three views 1, 2:
- Anteroposterior (AP) views in internal and external rotation
- Axillary or scapula-Y view (critical for detecting dislocations)
- Additional views such as the Stryker notch view for specific injuries (e.g., Hill-Sachs lesions)
- Radiographs should be performed upright, 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
Treatment Approach
- For non-surgical cases (most common), initiate conservative management including 3, 4:
- Short course of rest and ice
- Topical analgesics and NSAIDs for pain control
- Directed and supervised physical therapy
- Subacromial corticosteroid injections when appropriate
- Refer patients with unstable or significantly displaced fractures and joint instability for immediate surgical evaluation 1, 2
- Expedite surgical referral for traumatic massive rotator cuff tears to optimize functional outcomes 1, 2
Common Pitfalls and Considerations
- Patient factors such as age, comorbidities, and expected activity level significantly influence the appropriate management strategy 1, 2
- Delaying treatment of traumatic massive rotator cuff tears may lead to suboptimal functional outcomes 2
- Many shoulder conditions can be diagnosed without advanced imaging (MRI/CT), which should be reserved for cases where initial treatment fails or when specific diagnoses require confirmation 3
- Consider referral to an orthopedic surgeon for patients who fail an appropriate course of non-surgical treatment (typically 4-6 weeks) 5