Initial Evaluation of Shoulder Pain
The initial step in evaluating a patient with shoulder pain is obtaining standard radiographs, which should include at least three views: anteroposterior (AP) projections in internal and external rotation, plus an axillary lateral view or scapular Y view. 1
Why Radiography First
Radiography serves as the essential initial screening modality for acute shoulder pain of all causes, regardless of suspected etiology 2. This approach is safe, fast, and cost-effective while demonstrating many forms of shoulder pathology including fractures, dislocations, and degenerative changes 2.
Critical Technical Requirements
- Minimum three views with two orthogonal projections are mandatory for adequate evaluation 2, 1
- Upright positioning is essential, as shoulder malalignment can be underrepresented on supine imaging 1
- For trauma cases, a Grashey projection (30° posterior oblique) is recommended to properly profile the glenohumeral joint 2
Common Pitfall to Avoid
The axillary lateral or scapular Y view is non-negotiable when evaluating for instability or dislocation, as acromioclavicular and glenohumeral dislocations can be completely missed on AP views alone 1. However, exercise caution with the axillary view in recently dislocated shoulders, as the required positioning may cause redislocation 2.
Physical Examination Components
While radiography is the initial imaging step, the physical examination must assess:
- Inspection and palpation to localize the injury 3, 4
- Range of motion testing in all planes 4
- Rotator cuff strength assessment 4
- Provocative maneuvers for impingement, instability, and labral pathology 5
- Neurovascular integrity 4
The physical examination helps determine the mechanism of injury and whether surgical intervention may be needed 3.
Red Flags Requiring Urgent Attention
- Posterior sternoclavicular dislocations require urgent surgical referral 3
- Fever, unusual fatigue, or respiratory symptoms accompanying shoulder pain may indicate pulmonary or systemic pathology rather than musculoskeletal disease 6
- Displaced or unstable proximal humerus fractures warrant surgical consultation 3