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

Appropriate Workup for Left Shoulder Pain

Radiography is the preferred initial imaging modality for evaluating left shoulder pain, with a standard set of shoulder radiographs including anteroposterior (AP) views in internal and external rotation and an axillary or scapula-Y view. 1

Initial Evaluation

Radiographic Assessment

• Standard radiographic evaluation should include at least three views, with two being orthogonal 1:
  • Anteroposterior (AP) views in internal and external rotation
  • Axillary lateral view or scapular Y view (essential for detecting dislocations) 1
• Radiographs should be performed upright, as shoulder malalignment can be underrepresented on supine imaging 1
• Additional specialized views may be indicated based on clinical suspicion:
  • Grashey projection (30° posterior oblique) to profile the glenohumeral joint 1
  • Rockwood view or suprascapular outlet view for evaluating impingement and anterior acromion 1
  • Westpoint view for detecting bony Bankart lesions 1
  • Stryker notch view for evaluating Hill-Sachs deformities 1

Further Imaging Based on Initial Findings

• If radiographs are noncontributory and labral tear/instability is suspected (especially in patients <35 years):

  • MR arthrography is the gold standard (rated 9/9 for appropriateness) 1
  • Standard MRI without contrast is a reasonable alternative (rated 7/9) 1
  • CT arthrography may be appropriate if MRI is contraindicated (rated 5/9) 1

• For suspected rotator cuff pathology after noncontributory radiographs:

  • MRI without contrast or ultrasound (both rated 9/9, depending on local expertise) 1
  • MR arthrography for distinguishing between full and partial thickness tears 1

• For suspected fractures requiring better characterization:

  • CT provides superior fracture pattern delineation 1
  • CT is particularly valuable for preoperative planning of complex fractures 1

Special Considerations

• For suspected septic arthritis:

  • Ultrasound or fluoroscopic-guided arthrocentesis is the procedure of choice (both rated 9/9) 1
  • Aspiration and fluid analysis are essential for diagnosis 1

• When evaluating post-surgical shoulders:

  • MRI, MR arthrography, and ultrasound are all appropriate (rated 9/9) depending on local expertise 1
  • CT may be valuable for evaluating metallic hardware using optimized protocols 1

Red Flags Requiring Urgent Referral

• Be alert for symptoms suggesting non-musculoskeletal causes of shoulder pain:
  • Shoulder pain with dyspnea, cough, fever, or unusual fatigue may indicate pulmonary pathology 2
  • Night pain unrelated to position changes may suggest malignancy 3
  • Acute traumatic injuries with significant displacement or instability require urgent specialist referral 3

Clinical Pearls

• Axillary or scapula-Y views are vital in evaluating traumatic shoulder injuries, as acromioclavicular and glenohumeral dislocations can be misclassified on AP views alone 1
• The position required for axillary lateral views may be painful for patients who have recently dislocated their shoulders; care should be taken to avoid redislocation 1
• MR arthrography is superior to standard MRI for evaluating intra-articular pathology such as labral tears and capsular injuries 1
• Most soft-tissue injuries (labral tears, rotator cuff tears) can undergo conservative management initially, while unstable fractures and joint instability often require acute surgical intervention 1