What is the initial approach to managing unilateral clavicular pain radiating to the shoulder and upper back?

Initial Approach to Unilateral Clavicular Pain Radiating to Shoulder and Upper Back

The initial approach to managing unilateral clavicular pain radiating to the shoulder and upper back should begin with radiographic imaging, including anteroposterior views in internal and external rotation and an axillary or scapula-Y view, performed in an upright position. 1

Diagnostic Imaging

• Standard radiography is the preferred initial study for evaluating clavicular pain, as it can effectively demonstrate fractures, dislocations, and shoulder malalignment 1
• A complete radiographic evaluation should include at least three views: anteroposterior (AP) views in internal and external rotation, plus an axillary or scapula-Y view 1
• Radiographs should be performed with the patient in an upright position, as malalignment can be underrepresented on supine imaging 1
• If radiographs are noncontributory but symptoms persist, advanced imaging may be necessary:
  • MRI without contrast (rating 7/9) or MR arthrography (rating 9/9) for suspected soft tissue injuries 1
  • CT scan for better characterization of fracture patterns when radiographs show bony abnormalities 1

Common Causes and Evaluation

• Consider stress fracture of the clavicle, which can present with atypical pain patterns radiating to the shoulder, arm, and upper thorax 2
• Evaluate for distal clavicular osteolysis, particularly in athletes or those performing repetitive overhead activities, which presents with tenderness localized to the acromioclavicular joint 3
• Assess for rotator cuff disorders, adhesive capsulitis, acromioclavicular osteoarthritis, glenohumeral osteoarthritis, or shoulder instability as potential causes 4
• Examine for neurological symptoms, as some clavicular injuries can affect nearby nerves, causing radiating pain and numbness 5, 2

Initial Treatment Approach

• Activity modification and analgesic medications comprise the initial treatment for most cases of clavicular pain 4
• First-line pharmacologic treatment for mild to moderate pain includes:
  • Acetaminophen or NSAIDs, with the choice depending on the type of pain and patient risk factors 6
  • Consider the cardiovascular, gastrointestinal, and renal risk profiles when selecting NSAIDs 6
• For pain unresponsive to first-line agents, consider:
  • Physical therapy focused on the specific diagnosis 4
  • Combined steroid and local anesthetic injections at the appropriate site (subacromial, acromioclavicular joint, or intra-articular) 4
  • For severe acute pain related to clavicular fractures, consider ultrasound-guided clavipectoral plane block as an effective analgesic option with low risk profile 7

When to Refer

• Symptoms that persist or worsen after 6-12 weeks of directed treatment should be referred to an orthopedic specialist 4
• Immediate referral is warranted for:
  • Unstable or significantly displaced fractures 1
  • Presence of neurological deficits 5
  • Shoulder joint instability 1

Common Pitfalls to Avoid

• Inadequate imaging leading to missed fracture components or underestimation of injury severity 5
• Failing to obtain orthogonal views, which can result in misclassification of acromioclavicular and glenohumeral dislocations 1
• Overlooking stress fractures of the clavicle in patients with atypical pain presentations 2
• Delaying referral for surgical intervention when indicated, which can make stabilization more technically challenging 5