Treatment for Acute Shoulder Pain with Popping and Clicking After Possible Injury
Begin with standard shoulder radiographs (AP views in internal and external rotation plus axillary or scapula-Y view) to rule out fracture or dislocation, then initiate conservative management with sling immobilization for comfort and early targeted rehabilitation unless imaging reveals surgical pathology. 1
Initial Diagnostic Imaging
Radiographs are the mandatory first step in evaluating acute traumatic shoulder pain with mechanical symptoms like popping and clicking. 1
- Obtain a minimum 3-view series: anteroposterior views in both internal and external rotation, plus either an axillary or scapula-Y view 1
- The axillary or scapula-Y view is critical—glenohumeral and acromioclavicular dislocations are frequently misclassified on AP views alone 1
- Perform radiography with the patient upright when possible, as supine positioning can underrepresent shoulder malalignment 2
- Radiographs identify fractures, dislocations, and guide whether surgical versus conservative management is appropriate 1
Advanced Imaging Considerations
If radiographs are normal or indeterminate but symptoms persist, consider MRI without contrast as the next step. 1
- MRI without IV contrast can identify rotator cuff tears, labral injuries, osseous contusions, and acromioclavicular sprains that explain popping/clicking symptoms 1
- In the acute post-traumatic setting, non-contrast MRI is preferred over MR arthrography 1
- CT without contrast is reserved for characterizing complex fracture morphology when radiographs show fractures but surgical planning requires more detail 1
- Ultrasound has limited utility in acute trauma unless specifically evaluating rotator cuff or biceps tendon pathology, and is operator-dependent 1
Conservative Management Protocol
Most acute shoulder injuries can be managed non-operatively initially. 3, 4
- Provide sling immobilization for comfort during the acute phase (typically first few days to 2 weeks depending on injury severity) 3
- Initiate targeted musculoskeletal rehabilitation program early, focusing on restoring range of motion followed by progressive strengthening 3, 5
- Physical therapy should address scapular coordination and rotator cuff function, as scapular dyskinesis commonly contributes to ongoing symptoms 6
- Over 80% of common shoulder injuries including most clavicle fractures and humeral head fractures can be managed conservatively 4
Indications for Surgical Referral
Urgent surgical consultation is required for:
- Posterior sternoclavicular dislocations (urgent referral) 3
- Types IV, V, and VI acromioclavicular joint injuries 3, 4
- Displaced or unstable proximal humerus fractures 3, 4
Consider surgical consultation for:
- Middle third clavicle fractures in active individuals 3
- Type III acromioclavicular sprains in active patients (controversial—some manage conservatively) 3, 4
- First-time glenohumeral dislocation in young athletes 3
- Full-thickness rotator cuff tears, particularly if traumatic and massive (expedited timeline improves functional outcomes) 1, 3
Common Pitfalls to Avoid
- Do not skip the axillary or scapula-Y view—this is where dislocations are missed on AP-only series 1
- Do not assume absence of fracture in elderly patients even with minimal trauma history, as osteoporotic fractures occur with trivial mechanisms 6
- Do not delay imaging if clinical suspicion is high for structural pathology, even if symptoms seem mild 7
- Popping and clicking specifically suggest labral pathology, cartilage injury, or instability—if symptoms persist beyond 2-4 weeks of conservative care with normal radiographs, obtain MRI 1, 6
Age-Specific Considerations
- Patients under 35 years: Prioritize evaluation for instability, labral tears, and sports-related injuries as primary causes of mechanical symptoms 1, 6
- Patients over 35-40 years: Focus on rotator cuff disease and degenerative changes as predominant pathology, though traumatic tears still require identification 1, 6