What is the recommended evaluation and treatment approach for a patient presenting with shoulder pain?

Shoulder Pain Evaluation

Begin with standard radiographs (AP, Grashey, and axillary or scapular Y views) for all patients presenting with shoulder pain, then tailor advanced imaging based on age and clinical findings: MRI/ultrasound for rotator cuff pathology in patients ≥35 years, and MR arthrography for labral pathology in patients <35 years. 1

Initial Clinical Assessment

History and Physical Examination Priorities

Age-specific differential diagnosis:

• Patients <35 years: Suspect labral tears and glenohumeral instability, particularly with history of recurrent subluxation, "dead arm" sensation, or mechanical symptoms 1
• Patients ≥35 years: Rotator cuff disease predominates, with symptoms including pain during overhead activities, night pain, and weakness with external rotation or abduction 1

Red flags requiring urgent referral:

• Fever with joint effusion (septic arthritis) 1
• Acute neurologic deficits 1
• Suspected cardiac or pulmonary pathology 1

Physical Examination Technique

Patient positioning:

• Seat patient with 90° elbow flexion and hand supinated on thigh 2
• Perform active and passive external/internal rotation through full range of motion with 90° flexed elbow 2

Range of motion assessment:

• Forward flexion: 0-180° 2
• External rotation: 0-90° 2
• Internal rotation: ability to reach up the back 2

Specific muscle testing:

• Supraspinatus: empty can test (Jobe's test) 2
• Infraspinatus/teres minor: resisted external rotation 2
• Subscapularis: lift-off test and belly press test 2
• Biceps tendon: Speed's test and Yergason's test 1

Palpation points:

• Acromioclavicular joint, sternoclavicular joint, bicipital groove 2
• Proximal humerus and surrounding soft tissues for tenderness 2
• Assess for swelling, warmth, or crepitus indicating inflammation 2

Additional assessments:

• Evaluate scapular position and movement for winging or dyskinesia 2
• Perform neurovascular examination of the upper extremity 3

Imaging Algorithm

Initial Imaging for All Patients

Radiography is mandatory as first-line imaging:

• Minimum 3 views: AP, Grashey, and axillary or scapular Y projections 1
• For traumatic presentations, these views evaluate for proximal humerus, clavicle, or scapular fractures 1
• Dedicated AC joint views for suspected acromioclavicular joint injury 1
• Orthogonal views to confirm glenohumeral dislocation and identify Hill-Sachs deformity or bony Bankart lesions 1

Advanced Imaging Based on Clinical Findings

If fracture identified on radiographs:

• CT without contrast to characterize fracture complexity, displacement, and surgical planning 1
• Multidetector CT produces high-quality isotropic imaging helpful for evaluating shoulders with metallic hardware 4

For suspected rotator cuff tear (typically ≥35 years):

• MRI without contrast OR ultrasound are equivalent first-line studies 1
• Choice depends on local expertise; ultrasound is operator-dependent but excellent for rotator cuff and biceps tendon pathology 4
• MRI evaluates deep shoulder structures and marrow that ultrasound cannot assess 4

For suspected labral tear (typically <35 years):

• Acute trauma: MRI without contrast is preferred because hemarthrosis provides natural joint distention 1
• Subacute/chronic presentation: MR arthrography is the reference standard, using intra-articular gadolinium injection to distend the joint and outline labral and capsular structures 4, 1

For suspected instability/dislocation:

• MRI without IV contrast is the primary study 1
• CT without contrast when bone loss assessment is critical for surgical planning 1

For suspected septic arthritis:

• Ultrasound-guided or fluoroscopy-guided arthrocentesis is the procedure of choice (both rated 9/9 by ACR) 4
• Imaging is used for guidance rather than diagnosis 1
• MRI with and without contrast may be appropriate if clinical concern warrants after aspiration 4

Treatment Approach

Conservative Management (First-Line)

Pharmacologic therapy:

• NSAIDs: ibuprofen 400-800 mg three to four times daily 1
• Acetaminophen for pain management if no contraindications 2
• Neuromodulating medications (gabapentin or pregabalin) when sensory changes, allodynia, or hyperpathia are present 1

Non-pharmacologic therapy:

• Structured exercise programs with physiotherapy 1, 5
• Patient education on positioning, ergonomics, and activity modification 1
• Gentle stretching and mobilization techniques, focusing on external rotation and abduction 2
• Gradually increase active range of motion while strengthening weak shoulder girdle muscles 2

Interventional Options After Failed Conservative Management

Injection therapies:

• Corticosteroid injections for subacromial pain related to rotator cuff or bursa inflammation, though evidence is limited 1, 2
• Suprascapular nerve blocks 1
• Botulinum toxin injections 1

Surgical Referral Indications

Urgent referral:

• Acute fractures requiring fixation 1
• Progressive neurological deficits 1

Elective referral:

• Failed adequate conservative management 1, 5
• Severe restrictions in range of motion with muscle contractures 1

Common Pitfalls

Age-based imaging errors:

• Ordering MR arthrography in acute trauma wastes resources; hemarthrosis provides natural distention making intra-articular contrast unnecessary 1
• Failing to consider instability in younger patients or rotator cuff disease in older patients leads to inappropriate imaging selection 4, 1

Missed diagnoses:

• Cervical spine pathology can refer pain to the shoulder; always evaluate the neck 3
• Thoracic outlet syndrome, lung neoplasms, and subdiaphragmatic infections can present as shoulder pain 6
• Complex Regional Pain Syndrome may develop post-stroke with signs including edema, trophic skin changes, and hyperesthesia 2

Imaging overutilization:

• CT is inferior to MRI for soft tissue injuries and should be reserved for fracture characterization 2
• Ultrasound is limited in evaluating deep shoulder structures and marrow despite being excellent for rotator cuff assessment 4