Treatment Options for Shoulder Pain Radiating to Upper Arm
Begin with plain radiography as your initial diagnostic step, then proceed to conservative management for most soft-tissue injuries, reserving surgery for unstable fractures, significant dislocations, or cases failing conservative treatment. 1
Initial Diagnostic Approach
Start with standard radiography including at least three views: anteroposterior (AP) projections in internal and external rotation, plus an axillary or scapula-Y view performed upright. 1 This imaging effectively identifies fractures, dislocations, and shoulder malalignment—the primary concerns requiring immediate intervention. 1
When Radiographs Are Noncontributory
If initial radiographs are normal but symptoms persist, your next steps depend on clinical suspicion:
For suspected rotator cuff pathology or bursitis: MRI without contrast (rated 9/9) or ultrasound (rated 9/9) are equally appropriate. 1 Both modalities effectively evaluate the rotator cuff, subacromial bursa, and biceps tendon. 1
For suspected labral tears or instability (particularly in patients <35 years): MR arthrography is the gold standard (rated 9/9), though non-contrast MRI is also appropriate (rated 7/9). 1
For suspected septic arthritis: Perform immediate arthrocentesis under ultrasound or fluoroscopic guidance (both rated 9/9) to obtain synovial fluid for analysis. 1
Conservative Management Strategy
Most soft-tissue injuries including labral tears and rotator cuff tears should undergo conservative management before considering surgery. 1 This approach is appropriate for:
- Low-grade acromioclavicular separations 1
- Acute rotator cuff tears without significant displacement 1
- Rotator cuff tendinosis/tendinopathy 1
- Subacromial bursitis 1
- Biceps tenosynovitis 1
Conservative treatment includes physiotherapy, with consideration for ultrasound or fluoroscopy-guided injections of anesthetic and/or corticosteroid when clinically warranted. 1, 2
Surgical Indications
Immediate surgical referral is required for:
- Unstable or significantly displaced fractures 1
- Joint instability requiring acute stabilization 1
- Glenohumeral or acromioclavicular dislocations that cannot be reduced 1
Delayed surgical referral is appropriate for:
- Patients failing an adequate trial of conservative management 2
- Full-thickness rotator cuff tears with tendon retraction, muscle atrophy, or fatty infiltration 1
- Recurrent instability despite rehabilitation 1
Common Pitfalls to Avoid
Do not rely solely on AP radiographs for trauma evaluation—acromioclavicular and glenohumeral dislocations can be missed without axillary or scapula-Y views. 1
Perform radiographs upright rather than supine, as shoulder malalignment can be underrepresented on supine imaging. 1
Recognize that 10% of rotator cuff tears are asymptomatic, presenting only with morphologic changes on imaging. 1 Clinical correlation is essential.
Consider referred pain sources including cervical spine pathology, thoracic outlet syndrome, lung neoplasms, or subdiaphragmatic infections when musculoskeletal examination is unremarkable. 3, 4
Pain Pattern Recognition
Shoulder pain radiating to the upper arm is characteristic of subacromial impingement and rotator cuff pathology, typically presenting as sharp anterior shoulder pain with dull, aching radiation down the arm. 5 This pattern helps differentiate from acromioclavicular joint pathology (well-localized anterosuperior pain) or glenohumeral arthritis (severe pain affecting the entire arm). 5