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

Evaluation of Shoulder Pain

Start with plain radiographs (minimum 3 views: AP, Grashey, and axillary or scapular Y) as the initial imaging for all patients presenting with shoulder pain, regardless of mechanism. 1

Initial Clinical Assessment

Red Flags Requiring Urgent Evaluation

• Fever with joint effusion suggesting septic arthritis 1
• Acute neurologic deficits 1
• Suspected cardiac or pulmonary pathology causing referred pain 1
• Acute trauma with suspected fracture or dislocation 1

Age-Stratified Differential Diagnosis

Patients Under 35 Years:

• Labral tears and glenohumeral instability are the primary concerns 1
• Key historical features include recurrent subluxation, "dead arm" sensation, or mechanical symptoms 1
• Look for Hill-Sachs deformity or bony Bankart lesions on radiographs 1

Patients 35 Years and Older:

• Rotator cuff disease becomes the predominant pathology 1
• Characteristic symptoms include pain with overhead activities, night pain, and weakness with external rotation or abduction 1
• Biceps tendon pathology presents with anterior shoulder pain and positive Speed's or Yergason's test 1

Physical Examination Priorities

• Evaluate tone, strength, soft tissue length changes, and joint alignment of the shoulder girdle 2
• Assess range of motion in all planes, particularly external rotation and abduction 2
• Perform provocative testing for impingement, instability, and specific tendon pathology 1
• Complete sensorimotor examination of the upper extremity to identify neuropathic features 3

Imaging Algorithm After Initial Radiographs

If Fracture Identified:

• Order CT without contrast to characterize fracture complexity, displacement, and aid surgical planning 1

If Suspected Instability/Dislocation:

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

If Suspected Labral Tear:

• MR arthrography is the reference standard in subacute/chronic settings 1
• MRI without contrast is preferred in acute trauma because hemarthrosis provides natural joint distention 1

If Suspected Rotator Cuff Tear:

• MRI without contrast or ultrasound are equivalent first-line studies 1
• Choice depends on local expertise and availability 1
• Ultrasound may be preferred if significant metallic artifact from prior surgery would limit MRI quality 3

If Suspected Septic Arthritis:

• Ultrasound-guided or fluoroscopy-guided arthrocentesis is the diagnostic procedure of choice 1

Treatment Approach Based on Diagnosis

Conservative Management (First-Line for Most Non-Urgent Pathology)

Pharmacologic Management:

• NSAIDs such as ibuprofen 400-800 mg three to four times daily 1
• Acetaminophen for pain relief when no contraindications exist 2
• Neuromodulating medications (gabapentin or pregabalin) when neuropathic features are present, including electric shock sensations, sensory changes, allodynia, or hyperpathia 3, 1

Physical Therapy:

• Gentle stretching and mobilization techniques for pain related to range of motion limitations, focusing on increasing external rotation and abduction 2
• Active range of motion should be increased gradually while restoring alignment and strengthening weak shoulder girdle muscles 2
• Structured exercise programs with scapular stabilization 3
• Active, active-assisted, or passive range of motion exercises to prevent complex regional pain syndrome 2

Activity Modification:

• Patient education on positioning and ergonomics 1
• Avoid repetitive overhead movements that trigger symptoms during the acute phase 3

Interventional Options After Failed Conservative Management

Injection Therapies:

• Botulinum toxin injections into subscapularis and pectoralis muscles for hemiplegic shoulder pain related to spasticity 2
• Subacromial corticosteroid injections when pain is related to injury or inflammation of the rotator cuff or bursa 2
• Suprascapular nerve blocks 1

Surgical Referral Indications

• Acute fractures requiring fixation 1
• Failed adequate conservative management (typically 6-8 weeks) 1
• Progressive neurological deficits 1
• Severe restrictions in range of motion with muscle contractures 1

Critical Pitfalls to Avoid

• Do not dismiss neuropathic symptoms as "normal postoperative pain"—these require specific evaluation for nerve pathology and targeted treatment with neuromodulating agents rather than just NSAIDs 3
• Do not order MR arthrography in the acute postoperative setting—standard MRI without contrast is sufficient and appropriate 3
• Do not skip initial radiographs—they are essential for all presentations before advanced imaging 1
• Do not delay urgent referral for red flag diagnoses including septic arthritis, acute neurologic deficits, or fractures requiring fixation 1