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

Management of Left Shoulder Pain

The appropriate management for a patient presenting with left shoulder pain should begin with standard radiography including anteroposterior views in internal and external rotation plus an axillary or scapular Y view, followed by advanced imaging such as MRI, MR arthrography, or ultrasound based on clinical suspicion and local expertise. 1

Initial Diagnostic Approach

• Standard radiography is the preferred initial imaging modality for evaluating shoulder pain, as it can effectively demonstrate fractures, dislocations, and shoulder malalignment 1
• Radiographs should be performed with the patient in an upright position, as malalignment can be underrepresented on supine imaging 2
• A complete radiographic shoulder examination should include at least three views:
  • Anteroposterior (AP) views in internal and external rotation
  • Axillary lateral view or scapular Y view 1

Advanced Imaging

If radiographs are noncontributory but symptoms persist, advanced imaging may be necessary:

• MRI without contrast (rated 7/9 for appropriateness), MR arthrography (rated 9/9), or ultrasound (rated 9/9) are equivalent options depending on local expertise and suspected pathology 1
• For patients under 35 years with suspected labral tear or instability, MR arthrography is generally recommended 1
• For patients over 35 years, standard MRI is typically sufficient as shoulder pain is predominantly related to rotator cuff disease 1
• If MRI or ultrasound cannot be performed, CT arthrography or X-ray arthrography may be considered (rated 5/9) 1

Treatment Based on Specific Diagnoses

For Suspected Septic Arthritis

• Ultrasound or X-ray guided arthrocentesis is the procedure of choice (both rated 9/9) 1
• MRI with and without contrast may be appropriate if clinical concern warrants (rated 7/9) 1

For Traumatic Injuries

• Unstable or significantly displaced fractures and joint instability may require acute surgical management 1
• Soft tissue injuries including labral tears and rotator cuff tears may undergo a period of conservative management 1

For Shoulder Pain Prevention and Treatment

• Avoid overhead pulleys which encourage uncontrolled abduction 1
• Consider the following interventions:
  • Electrical stimulation to improve shoulder lateral rotation 1
  • Shoulder strapping or sling 1
  • Intra-articular steroid injections (Triamcinolone) 1, 3
  • Range of motion exercises through stretching and mobilization techniques focusing on external rotation and abduction 1
  • Modalities including ice, heat, and soft tissue massage 1
  • Functional electrical stimulation 1
  • Strengthening exercises 1

Common Pitfalls to Avoid

• Inadequate imaging leading to missed fracture components or underestimation of injury severity 2
• Failure to obtain orthogonal views, which can lead to misclassification of acromioclavicular and glenohumeral dislocations 2
• Delaying referral for surgical intervention when indicated, which can make stabilization more technically challenging 2
• Overlooking non-musculoskeletal causes of shoulder pain such as referred pain from cervical spine, peripheral nerves, lung disease, or subdiaphragmatic processes 4

When to Refer to a Specialist

• Symptoms that persist or worsen after 6-12 weeks of directed treatment 5
• Presence of neurological deficits 2
• Unstable or significantly displaced fractures 1
• Shoulder joint instability 1
• Suspected massive rotator cuff tears that may require expedited repair for optimal outcomes 1