What is the best course of treatment for a 16-year-old patient with scoliosis, shoulder pain, and crepitus (popping and crunching sounds) in both shoulders?

Management of Shoulder Pain and Crepitus in a 16-Year-Old with Scoliosis

This adolescent requires referral to a pediatric orthopedic surgeon for comprehensive evaluation of both the scoliosis and bilateral shoulder symptoms, as significant spinal deformity in this age group warrants specialist assessment. 1

Immediate Referral Criteria

Refer to a pediatric orthopedic surgeon for any adolescent with significant spinal deformity (scoliosis), as recommended by the American Academy of Pediatrics. 1 The bilateral shoulder pain with crepitus occurring in the context of scoliosis suggests potential biomechanical dysfunction related to the spinal curvature, which requires specialist evaluation to determine if the shoulder symptoms are secondary to postural compensation or represent a separate pathology. 1

Diagnostic Evaluation Required

The orthopedic specialist should perform:

• Assessment of scoliosis severity using standing posteroanterior and lateral radiographs with Cobb angle measurement to determine curve magnitude and progression risk. 2, 3

• Evaluation for underlying syndromic causes, particularly if there are atypical features. The presence of learning disability warrants consideration of genetic syndromes that can present with both scoliosis and connective tissue manifestations affecting the shoulders. 4

• Shoulder-specific examination including evaluation of glenohumeral joint alignment, range of motion (particularly external rotation and abduction), scapular positioning, and assessment for rotator cuff pathology or instability. 1

• Radiographic evaluation of both shoulders as the initial imaging modality to assess for structural abnormalities, subluxation, or degenerative changes that could explain the crepitus. 1

Treatment Approach for Shoulder Symptoms

While awaiting specialist evaluation, conservative management can be initiated:

• Gentle stretching and mobilization techniques focusing on increasing external rotation and abduction if range of motion is limited. Active range of motion should be increased gradually in conjunction with strengthening weak muscles in the shoulder girdle. 1

• Analgesics such as acetaminophen or ibuprofen can be used for pain relief if there are no contraindications. 1

• Avoid aggressive manipulation or positioning that could exacerbate symptoms, as the evidence for static positioning and strapping to prevent shoulder problems is not well established. 1

Scoliosis Management Considerations

The treatment approach for scoliosis depends on:

• Curve magnitude: Observation for curves <20°, bracing consideration for curves 20-50° in skeletally immature patients, and surgical intervention typically recommended for curves >50° or rapidly progressive curves. 5, 2

• Skeletal maturity: This 16-year-old is likely approaching or at skeletal maturity, but curves >50° may continue to progress at approximately 1° per year even after skeletal maturity. 5

• Risk of progression: Thoracic curves and larger curves in skeletally immature individuals have higher progression risk (>70% for curves >20° in immature patients). 5

Critical Pitfalls to Avoid

• Do not dismiss bilateral shoulder symptoms as purely mechanical without ruling out underlying connective tissue disorders or syndromic causes, especially given the combination of scoliosis and learning disability. 4

• Do not delay referral waiting for symptoms to worsen, as both scoliosis and shoulder pathology may progress during adolescent growth spurts. 1, 2

• Avoid relying solely on clinical examination for scoliosis assessment; radiographic evaluation with Cobb angle measurement is essential for determining treatment. 3

• Consider MRI evaluation before any surgical intervention to rule out neural axis abnormalities, particularly if there are atypical features such as rapid progression, pain, or neurological findings. 5

Advanced Imaging Indications

If initial radiographs are noncontributory and symptoms persist:

• MRI of the shoulders without contrast is the procedure of choice for evaluating soft tissue structures including rotator cuff, labrum, and cartilage in adolescents with shoulder pain and suspected instability. 1

• Ultrasound with appropriate expertise is excellent for depicting rotator cuff pathology and can guide interventions if needed. 1