What are the diagnostic and management steps for right shoulder pain?

Diagnostic Evaluation for Right Shoulder Pain

Begin with standard three-view radiography (AP in internal and external rotation plus axillary or scapular Y view) as the initial imaging study for all presentations of right shoulder pain, regardless of whether the mechanism is traumatic or atraumatic. 1, 2

Initial Clinical Assessment

Age-Stratified Differential Diagnosis

• Patients under 35 years: Suspect labral tears, glenohumeral instability, and labroligamentous injuries, particularly with history of recurrent subluxation, "dead arm" sensation, or mechanical symptoms 2, 3
• Patients 35 years and older: Rotator cuff disease becomes the primary concern, presenting with pain during overhead activities, night pain, and weakness with external rotation or abduction 2, 3
• Patients over 50 years: Consider glenohumeral osteoarthritis presenting as gradual pain and progressive loss of motion 3

Critical Red Flags Requiring Urgent Referral

• Fever with joint effusion suggesting septic arthritis 2
• Acute neurologic deficits 2
• Suspected cardiac or pulmonary pathology 2

Physical Examination Components

Positioning and Range of Motion

• Position patient sitting with 90° elbow flexion and hand supinated on the thigh 4
• Assess both active and passive range of motion: forward flexion (0-180°), external rotation (0-90°), and internal rotation (ability to reach up the back) 4
• Evaluate scapular position for winging or dyskinesia 4

Specific Provocative Tests

• Rotator cuff assessment: Empty can test (supraspinatus), external rotation strength (infraspinatus/teres minor), lift-off test and belly press (subscapularis) 4
• Impingement signs: Pain with overhead activity combined with positive impingement testing 3
• Biceps pathology: Speed's test and Yergason's test for anterior shoulder pain 2
• AC joint: Cross-body adduction test with superior shoulder pain and AC joint tenderness 3
• Instability: Apprehension and relocation tests in patients under 40 years with history of dislocation 3

Palpation

• Examine proximal humerus, AC joint, sternoclavicular joint, and bicipital groove for tenderness 4
• Identify swelling, warmth, or crepitus indicating inflammation 4

Imaging Algorithm Based on Clinical Findings

If Radiographs Show Fracture

• Order CT without contrast to characterize fracture complexity, displacement, angulation, and for surgical planning 1, 2
• CT is superior to radiography for delineating fracture patterns but inferior to MRI for soft tissue evaluation 1

If Suspected Glenohumeral Instability or Dislocation

• MRI without IV contrast is the primary study for soft tissue evaluation 2
• CT without contrast should be considered when bone loss assessment (Hill-Sachs deformity, bony Bankart lesions) is critical for surgical planning 2

If Suspected Labral Tear

• MR arthrography is the reference standard in subacute or chronic settings 1, 2
• MRI without contrast is preferred in acute trauma because hemarthrosis provides natural joint distention 2
• MR arthrography is superior to noncontrast MRI for diagnosing SLAP tears and labroligamentous injuries 1

If Suspected Rotator Cuff Tear

• MRI without contrast or ultrasound are equivalent first-line studies, with choice depending on local expertise 1, 2
• Both modalities are excellent for depicting rotator cuff and biceps pathology in preoperative and postoperative settings 1
• A clinical decision rule supporting rotator cuff tear includes: pain with overhead activity, weakness on empty can and external rotation tests, and positive impingement sign 3

If Suspected Septic Arthritis

• Ultrasound-guided or fluoroscopy-guided arthrocentesis is the procedure of choice 1, 2
• Imaging is used for procedural guidance rather than diagnosis; aspiration with synovial fluid analysis is definitive 1
• MRI with and without contrast may be appropriate if clinical concern warrants additional evaluation after aspiration 1

If Suspected Adhesive Capsulitis

• Clinical diagnosis is made by diffuse shoulder pain with restricted passive range of motion on examination 3
• Associated with diabetes and thyroid disorders 3
• Radiographs are typically normal; advanced imaging is not routinely needed unless diagnosis is unclear 2

Conservative Management Approach

First-Line Treatment

• NSAIDs: Ibuprofen 400-800 mg three to four times daily 2
• Structured exercise programs with patient education on positioning, ergonomics, and activity modification 2
• Gentle stretching and mobilization focusing on external rotation and abduction for range of motion limitations 4

Second-Line Options After Failed Conservative Management

• Neuromodulating medications (gabapentin or pregabalin) when sensory changes, allodynia, or hyperpathia are present 2
• Suprascapular nerve blocks 2
• Botulinum toxin injections 2
• Corticosteroid injections for subacromial pain related to rotator cuff or bursa inflammation, though evidence is limited 2, 4

Surgical Referral Indications

Refer to orthopedic surgery for:

• Acute fractures requiring fixation 2
• Failed adequate conservative management (typically 6-12 weeks) 2, 5
• Progressive neurological deficits 2
• Severe restrictions in range of motion with muscle contractures 2
• Unstable or significantly displaced fractures and joint instability requiring acute surgical treatment 1

Common Pitfalls to Avoid

• Do not rely on AP views alone for traumatic injuries, as glenohumeral and AC dislocations can be misclassified without axillary or scapular Y views 1
• Perform radiographs upright because shoulder malalignment can be underrepresented on supine imaging 1
• Do not order CT as initial imaging for shoulder pain; radiography is preferred because it adequately diagnoses displaced fractures and malalignment, which are the primary concerns 1
• Recognize that ultrasound is operator-dependent and limited for evaluating deep shoulder structures and marrow, despite being excellent for rotator cuff assessment 1