What are the recommended point of care tests for left shoulder pain?

Point of Care Testing for Left Shoulder Pain

Begin with standard three-view radiographs (AP in internal and external rotation plus axillary or scapular Y view) as your initial point of care imaging for all patients with left shoulder pain. 1, 2

Initial Radiographic Evaluation

• Obtain at least three radiographic views with two being orthogonal, specifically anteroposterior (AP) projections with the humerus in internal and external rotation, plus either an axillary lateral view or scapular Y view 1, 2
• Perform radiographs in the upright position, as shoulder malalignment can be underrepresented on supine imaging 2
• The axillary or scapular Y view is critical for detecting glenohumeral dislocations and instability, which can be missed on AP views alone 1, 2
• For trauma cases, include a Grashey projection (30° posterior oblique) to properly profile the glenohumeral joint 1

Clinical Examination Components at Point of Care

• Assess active and passive range of motion in all planes: forward flexion (0-180°), external rotation (0-90°), and internal rotation (ability to reach up the back) 3
• Test rotator cuff integrity using the empty can test (supraspinatus), external rotation resistance (infraspinatus/teres minor), and lift-off or belly press test (subscapularis) 3
• Palpate key structures including the acromioclavicular joint, bicipital groove, and proximal humerus for tenderness 3
• Perform provocative testing for impingement, instability (apprehension and relocation tests), and cross-body adduction for AC joint pathology 4, 5

Algorithm for Further Testing Based on Initial Findings

If Radiographs Are Normal and Rotator Cuff Pathology Suspected:

• Order MRI without contrast, MR arthrography, or ultrasound (all rated 9/9 appropriateness), with the choice depending on local expertise and availability 1, 2
• These three modalities are considered equivalent for rotator cuff evaluation when performed by experienced practitioners 1

If Radiographs Are Normal and Labral Tear/Instability Suspected (Age <35 Years):

• MR arthrography is the gold standard (rated 9/9) for detecting labral tears and capsular injuries 1, 2
• MR arthrography is superior to standard MRI because intra-articular gadolinium distends the joint and outlines labral and capsular structures 1, 2
• Standard MRI without contrast is acceptable (rated 7/9) if optimized imaging equipment is available 1

If Septic Arthritis Suspected:

• Perform immediate ultrasound-guided or fluoroscopic-guided arthrocentesis (both rated 9/9) for joint aspiration and fluid analysis 1, 2
• Aspiration with synovial fluid analysis is the definitive diagnostic procedure and takes priority over imaging 1

If Fracture Characterization Needed:

• Order CT imaging when radiographs show a fracture but more detail is needed for preoperative planning, particularly for complex fractures with displacement or angulation 1, 2
• Multidetector CT with reconstructed images provides superior fracture pattern delineation 1

Critical Pitfalls to Avoid

• Do not skip the axillary or scapular Y view in trauma cases, as glenohumeral and acromioclavicular dislocations are frequently misclassified on AP views alone 2
• Be cautious when positioning for axillary views in patients with acute dislocation, as this may cause redislocation 1
• In patients over 35 years, instability is more commonly related to rotator cuff disease rather than labral pathology, so standard MRI or ultrasound may be more appropriate than MR arthrography 1
• Ultrasound is highly operator-dependent and limited in evaluating deep shoulder structures and bone marrow, so ensure local expertise is available before relying on this modality 1

Red Flags Requiring Immediate Attention

• Assess for signs of septic arthritis: joint effusion, warmth, erythema, and fever requiring immediate arthrocentesis 1, 3
• Evaluate for Complex Regional Pain Syndrome: pain/tenderness, edema, trophic skin changes, hyperesthesia, and limited range of motion 3
• Screen for referred pain from cervical spine pathology or cardiac causes (particularly with left shoulder pain) through neurological examination and appropriate history 3, 6