What is the recommended evaluation and management for a patient with constant deep pain and occasional sharp pain in the left shoulder, particularly after a fall from a roof a couple of years ago, with a request for an x-ray?

Recommended Evaluation and Management for Chronic Shoulder Pain After Remote Trauma

Order standard shoulder radiographs immediately as the initial imaging study, including at least three views: anteroposterior (AP) in internal and external rotation plus an axillary or scapular Y view, performed upright. 1, 2

Initial Imaging Approach

Radiography is the appropriate first-line imaging modality for this patient, despite the chronicity of symptoms (2 years post-trauma). 1 The ACR Appropriateness Criteria establish that radiography is a safe, fast, low-cost imaging modality that effectively demonstrates many forms of shoulder pathology and serves as a useful initial screening modality for shoulder pain of all causes. 1

Key Technical Requirements for Shoulder Radiographs

• Minimum of 3 views with 2 orthogonal projections are required to avoid missing critical pathology 1, 2
• Upright positioning is essential because shoulder malalignment can be underrepresented on supine radiography 1
• Axillary or scapular Y views are vital as acromioclavicular and glenohumeral dislocations can be misclassified on AP views alone 1, 2

Clinical Context Supporting Radiography

The patient's presentation includes several features warranting imaging:

• Deep constant pain suggests potential chronic structural pathology that could include post-traumatic arthritis, chronic rotator cuff disease, or occult fracture malunion 1
• Sharp pain with weight-bearing suggests mechanical instability or impingement 1
• Remote high-energy trauma (fall from roof) increases fracture risk even years later due to potential malunion or post-traumatic changes 1

If Radiographs Are Noncontributory

Proceed to MRI without contrast (rating 7/9) or MR arthrography (rating 9/9) for suspected soft tissue injuries. 1, 2 The choice between these depends on clinical suspicion:

• MR arthrography (rating 9/9) is preferred if labral tear with or without instability is suspected on physical examination 1
• MRI without contrast (rating 9/9) is equally appropriate for suspected rotator cuff pathology 1
• Ultrasound (rating 9/9) is equivalent to MRI for rotator cuff evaluation when local expertise is available 1

Common Pitfalls to Avoid

• Do not skip orthogonal views - inadequate imaging leads to missed fracture components or underestimation of injury severity 2
• Do not assume chronicity excludes fracture - post-traumatic changes, malunion, or stress fractures can develop over time 1
• Do not order CT as initial imaging - CT is inferior to MRI for essentially all soft-tissue shoulder injuries and should be reserved for characterizing known bony abnormalities 1

Immediate Referral Indications

Refer immediately to orthopedic surgery if radiographs demonstrate: 2

• Unstable or significantly displaced fractures
• Shoulder joint instability or dislocation
• Presence of neurological deficits

Note that delaying referral for surgical intervention when indicated can make stabilization more technically challenging. 2

Management Based on Imaging Results

If radiographs show degenerative changes or chronic rotator cuff disease without acute fracture, most soft-tissue injuries can undergo conservative management before considering surgery. 1 However, the constant nature of this patient's pain over 2 years suggests conservative management may have already failed, warranting advanced imaging regardless of radiograph findings.