What is the most effective way to evaluate shoulder pain?

Efficient Shoulder Pain Examination

Begin with a focused 3-view radiographic series (AP in internal/external rotation plus axillary or scapular-Y view) as your initial imaging, then perform a systematic physical examination targeting the most common pathologies: rotator cuff integrity, labral tears, instability, and acromioclavicular joint disease. 1, 2

Initial Clinical Assessment

History - Key Red Flags to Identify

• Mechanism of injury: Traumatic versus atraumatic onset differentiates management pathways, as unstable fractures and dislocations require acute surgical intervention 1
• Age-specific patterns: Patients under 35 years predominantly have instability and labral pathology, while those over 35 years typically have rotator cuff disease 1
• Pain with overhead activities or throwing: Suggests rotator cuff pathology or impingement 3
• Night pain and inability to sleep on affected side: Classic for rotator cuff tears and subacromial bursitis 3
• Acute onset with inability to move shoulder: Consider septic arthritis, which requires emergent arthrocentesis 1

Physical Examination - Systematic Approach

Inspection and Palpation:

• Observe for visible asymmetry, swelling, or muscle atrophy while patient is seated with 90° elbow flexion 4, 5
• Assess scapular position and movement for winging or dyskinesia, which contributes to rotator cuff dysfunction 4
• Palpate the acromioclavicular joint, proximal humerus, and bicipital groove for point tenderness 4, 6

Range of Motion Testing:

• Evaluate both active and passive range of motion in forward flexion, abduction, internal rotation, and external rotation 6
• Restricted passive motion suggests adhesive capsulitis (frozen shoulder), while pain with active but not passive motion indicates rotator cuff pathology 3

Provocative Testing for Specific Pathologies:

• Rotator cuff tears: Test supraspinatus strength with empty can test (arm at 90° abduction, 30° forward flexion, thumb down) 3, 5
• Impingement: Perform Neer test (passive forward flexion) and Hawkins-Kennedy test (passive internal rotation at 90° flexion) 3, 5
• Labral tears/instability: Apprehension test (external rotation at 90° abduction) and relocation test are essential for anterior instability 5
• Biceps tendonitis: Speed's test (resisted forward flexion with elbow extended and forearm supinated) 3
• AC joint pathology: Cross-body adduction test reproduces pain 3

Imaging Algorithm

Initial Imaging - Always Start Here:

• Standard 3-view radiographic series must include AP views in internal and external rotation plus axillary or scapular-Y view 1, 2
• Critical caveat: Axillary or scapular-Y views are vital because glenohumeral and acromioclavicular dislocations can be missed on AP views alone 1, 2
• Perform radiographs upright, as supine positioning underrepresents shoulder malalignment 1, 2

Advanced Imaging - Based on Clinical Suspicion:

For patients under 35 years with suspected labral tear or instability:

• MR arthrography is the gold standard with appropriateness rating 9/9, superior to standard MRI for intra-articular pathology 1, 2
• Standard MRI without contrast is acceptable (rating 7/9) with optimized equipment 1

For patients over 35 years with suspected rotator cuff pathology:

• MRI without contrast, MR arthrography, or ultrasound are equivalent (all rated 9/9), depending on local expertise 1, 2
• Ultrasound is operator-dependent but excellent for full-thickness rotator cuff tears, though inferior for partial tears and intra-articular pathology 1

For complex fractures requiring surgical planning:

• CT provides superior fracture characterization including displacement, angulation, and complexity 1

For suspected septic arthritis:

• Ultrasound-guided or fluoroscopic-guided arthrocentesis (both rated 9/9) is the procedure of choice for diagnosis 1, 2

Common Pitfalls to Avoid

• Never rely on AP views alone for trauma evaluation, as this misses dislocations in up to 50% of cases without orthogonal views 1, 2
• Do not order MRI as initial imaging for acute shoulder pain; radiographs effectively identify fractures and dislocations that require immediate management 1
• Avoid assuming all shoulder pain originates from the shoulder; perform cervical spine and elbow examination to exclude referred pain 6
• Do not miss septic arthritis; if clinical suspicion exists, proceed directly to arthrocentesis rather than advanced imaging 1
• In pediatric patients (ages 11-15), specifically palpate the proximal humeral physis for tenderness indicating Little League shoulder, and obtain bilateral comparison radiographs if positive 4