Initial Assessment and Management of Shoulder Pain
Begin by determining whether the shoulder pain is traumatic or non-traumatic in origin, as this fundamentally dictates your diagnostic and management pathway. 1
Clinical History - Key Elements
Focus your history on these specific elements:
- Mechanism of injury: Determine if pain resulted from acute trauma, chronic repetitive injury, or arose spontaneously 1
- Range of motion status: Ask if the patient can move their shoulder through full range actively and passively, as this triages your differential diagnosis 2
- Red flag symptoms requiring urgent referral 1:
- Significant trauma with suspected fracture
- Joint instability or dislocation
- Neurological symptoms (weakness, numbness, paresthesias)
- Signs of infection or systemic illness
Physical Examination Approach
For patients with loss of both active AND passive range of motion, suspect adhesive capsulitis or glenohumeral arthritis 2
For patients with preserved passive range of motion, perform specific special tests to identify rotator cuff pathology, impingement, or labral tears 2
In post-stroke patients specifically, assess 3:
- Muscle tone and spasticity
- Soft tissue length changes
- Shoulder girdle joint alignment
- Orthopedic changes in the shoulder structure
Initial Imaging Protocol
Obtain three standard radiographic views performed upright 1:
- Anteroposterior (AP) views in both internal and external rotation
- Axillary view OR scapula-Y view
- Consider Stryker notch view for suspected Hill-Sachs lesions
Critical pitfall: Supine radiographs can miss shoulder malalignment; always obtain upright films 1. Failure to obtain axillary or scapula-Y views leads to missed acromioclavicular and glenohumeral dislocations 1.
Use ultrasound as a diagnostic tool for soft tissue injuries when available 3
Management Algorithm
Category 1: Acute Surgical Referral Required 1
Immediately refer patients with:
- Unstable or significantly displaced fractures
- Joint instability or dislocation
- Traumatic massive rotator cuff tears (expedited referral for optimal outcomes)
Category 2: Initial Conservative Management 1
Most soft-tissue injuries are appropriate for non-surgical treatment initially 4:
Pain control options:
- Acetaminophen or NSAIDs (ibuprofen) if no contraindications 3
- Subacromial corticosteroid injections for rotator cuff or bursal inflammation 3
- Neuromodulating medications for neuropathic pain with sensory changes, allodynia, or hyperpathia 3
Physical therapy interventions:
- Gentle stretching and mobilization techniques, focusing on external rotation and abduction 3
- Active range of motion exercises, gradually increased while restoring alignment and strengthening shoulder girdle muscles 3
- Avoid overhead pulley exercises - these are not recommended 3
For spasticity-related pain (particularly post-stroke):
- Botulinum toxin injections into subscapularis and pectoralis muscles 3
- Suprascapular nerve blocks may be considered as adjunctive treatment 3
Patient and family education on range of motion exercises and positioning is essential, particularly before discharge 3
Special Considerations
Post-stroke shoulder pain affects up to 29% of hemiplegic patients within the first year and requires specific assessment of tone, strength, soft tissue length, joint alignment, and pain levels 3
Age and activity level influence management strategy - consider patient comorbidities and functional expectations when determining conservative versus surgical approach 1
Failed conservative management: Refer to orthopedic surgery after appropriate trial of non-surgical treatment (typically 6-12 weeks) 4