What are the recommended treatments for left shoulder pain in children?

Left Shoulder Pain in Children: Diagnostic and Treatment Approach

Initial Assessment and Imaging

For pediatric left shoulder pain, begin with plain radiographs in at least three views (anteroposterior in internal and external rotation, plus axillary or scapula-Y view) to rule out fracture, dislocation, or malalignment. 1

Key Diagnostic Steps:

• Obtain upright radiographs as the initial imaging study, as shoulder malalignment can be underrepresented on supine films 1
• Axillary or scapula-Y views are vital because acromioclavicular and glenohumeral dislocations can be missed on AP views alone 1
• In pediatric patients, MRI without contrast is particularly sensitive for diagnosing physeal injuries and bone marrow contusions when radiographs are normal or indeterminate 1

Clinical Examination Priorities:

• Assess active and passive range of motion in all directions, noting any limitation by pain 2
• Evaluate for visible swelling, bruising, or deformity throughout the shoulder girdle 2
• Perform a thorough sensorimotor examination of the upper extremity 3

Treatment Based on Findings

For Traumatic Injuries (Post-Fall, Sports Injury):

If radiographs show fracture or dislocation, immediate orthopedic referral is indicated for potential surgical management. 1

• CT is superior to radiography for characterizing complex fracture patterns if more preoperative information is needed 1
• MRI without contrast is preferred over MR arthrography in acute trauma because joint effusion from injury facilitates assessment of intraarticular structures 1

For Soft Tissue Injuries or Normal Radiographs:

Begin conservative treatment with gentle stretching, mobilization techniques, and analgesics while gradually increasing active range of motion. 1, 4

Conservative Treatment Protocol:

• Pain management: Use acetaminophen or ibuprofen for analgesia 1
• Oral opioids may be appropriate for moderate to severe pain, with intranasal fentanyl as an alternative when IV access is unavailable 1
• Physical therapy: Focus on gentle stretching emphasizing external rotation and abduction 1, 4
• Gradually increase active range of motion while restoring alignment and strengthening weak shoulder girdle muscles 1, 4
• Educate patients and families on correct positioning and handling of the affected arm 4

Treatment Timeline:

• Initial phase (0-6 weeks): Conservative treatment with physical therapy, NSAIDs, activity modification, gentle stretching, and gradual strengthening 4
• Intermediate phase (6-12 weeks): Progress to advanced strengthening exercises for rotator cuff and scapular stabilizers if symptoms persist 4
• Advanced phase (12+ weeks): Focus on return to sport-specific activities with proper mechanics 4

Common Pitfalls to Avoid

• Do not delay imaging: Radiographs should be obtained promptly in any child with acute shoulder pain following trauma 1
• Do not withhold pain medication: There is no evidence that appropriate analgesia masks symptoms or prevents accurate diagnosis in children 1
• Do not miss glenohumeral dislocation: Always obtain axillary or scapula-Y views, as dislocations can appear normal on AP views alone 1
• Do not overlook physeal injuries: MRI is particularly valuable in pediatric patients for detecting growth plate injuries not visible on radiographs 1

When to Refer

• Unstable or significantly displaced fractures requiring acute surgical management 1
• Glenohumeral joint dislocation or instability 1
• Symptoms persisting beyond 6-8 weeks of conservative treatment 5
• Any "red flag" diagnoses requiring urgent specialist care 6