What are the steps for diagnosing and treating shoulder conditions?

Shoulder Diagnosis and Treatment Algorithm

Initial Clinical Assessment

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

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

History and Physical Examination Priorities

Position the patient sitting with 90° elbow flexion and hand in supination on top of the thigh for standardized examination. 2, 3

• Assess tone, strength, soft tissue length changes, and joint alignment of the shoulder girdle 2, 1
• Evaluate both active and passive range of motion in all planes: forward flexion (0-180°), external rotation (0-90°), and internal rotation (ability to reach up the back) 3
• Perform dynamic examination with active and/or passive external and internal rotation through full range of motion with 90° flexed elbow 2, 3
• Test rotator cuff muscles individually: supraspinatus (empty can test), infraspinatus and teres minor (external rotation), subscapularis (lift-off test, belly press test), and deltoid (resisted abduction) 3
• Assess scapular position and movement for winging or dyskinesia 3

Age-Specific Considerations

• Patients under 35 years: Primary concern is labral tears and glenohumeral instability; look for recurrent subluxation, "dead arm" sensation, or mechanical symptoms 1
• Patients over 50 years: Consider glenohumeral osteoarthritis presenting as gradual pain and loss of motion 4

Imaging Algorithm After Initial Radiographs

If Fracture Identified on Radiographs

Order CT without contrast to characterize fracture complexity, displacement, and aid surgical planning. 2, 1

• CT is particularly useful for humeral head/neck fractures and scapular fractures to document intra-articular extension and fragment angulation 2

If Suspected Instability or Dislocation

Order MRI without IV contrast as the primary study. 2, 1

• Consider CT without contrast when bone loss assessment is critical for surgical planning 1
• For Bankart or Hill-Sachs lesions detected on radiographs, both MRI without contrast and MR arthrography are appropriate 2

If Suspected Labral Tear

Order MR arthrography as the reference standard in subacute or chronic settings. 1, 3

• MRI without contrast is preferred in acute trauma 1
• CT arthrography is an alternative if MRI is contraindicated 2
• For patients under 35 years with instability or questionable labral pathology, use MRI or MR arthrography 3

If Suspected Rotator Cuff Tear

Order MRI without contrast or ultrasound as equivalent first-line studies, with choice depending on local expertise and availability. 1, 3

• Both modalities have high sensitivity and specificity for rotator cuff pathology 3

Treatment Approach Based on Diagnosis

Pharmacologic Management

Start with NSAIDs such as ibuprofen 400-800 mg three to four times daily for shoulder pain. 1

• Acetaminophen is recommended for pain relief when no contraindications exist 2, 1, 3
• Use neuromodulating medications (gabapentin or pregabalin) when neuropathic features are present, including electric shock sensations, sensory changes, allodynia, or hyperpathia 1

Physical Therapy Protocol

Implement gentle stretching and mobilization techniques focusing on increasing external rotation and abduction. 2, 5, 3

Initial Phase (0-6 weeks)

• Conservative treatment with physical therapy, NSAIDs, and activity modification 5
• Focus on gentle stretching, mobilization techniques, and gradual strengthening 5
• Gradually increase active range of motion while restoring alignment and strengthening weak shoulder girdle muscles 2, 3

Intermediate Phase (6-12 weeks)

• Progress to more advanced strengthening exercises for rotator cuff and scapular stabilizers 5
• Address biomechanical factors such as scapular dyskinesis 5
• Emphasize posterior shoulder musculature strengthening to counterbalance overdeveloped anterior muscles 5

Advanced Phase (12+ weeks)

• Focus on return to sport/work-specific activities with proper mechanics 5
• For overhead athletes, implement graduated throwing program emphasizing proper mechanics 5
• Ensure complete resolution of symptoms before returning to full activity 5

Injection Therapy

Use subacromial corticosteroid injections when pain is related to injury or inflammation of the subacromial region (rotator cuff or bursa). 2, 5, 3

• Ultrasound-guided injections provide accurate placement and may improve outcomes 5
• For spasticity-related hemiplegic shoulder pain, inject botulinum toxin into the subscapularis and pectoralis muscles 2

Special Condition Management

Complex Regional Pain Syndrome (CRPS)

Diagnose based on clinical findings: pain and tenderness of metacarpophalangeal and proximal interphalangeal joints, edema over dorsum of fingers, trophic skin changes, hyperesthesia, and limited range of motion. 2, 3

• Use triple phase bone scan (demonstrating increased periarticular uptake in distal upper extremity joints) to assist in diagnosis 2
• Start early oral corticosteroids at 30-50 mg daily for 3-5 days, then taper over 1-2 weeks to reduce swelling and pain. 2, 3
• Prevent CRPS with active, active-assisted, or passive range of motion exercises 2, 3

Shoulder Impingement Syndrome

Distinguish between primary impingement (structural) and secondary impingement (functional/dynamic) for appropriate treatment planning. 5

• Address scapular dyskinesis and rotator cuff weakness as essential for successful outcomes 5
• Identify and correct scapular winging or dyskinesis 5
• Assess and treat the entire kinetic chain, including core and spine mechanics 5

Critical Pitfalls to Avoid

Never skip initial radiographs—they are essential for all presentations before advanced imaging. 1

• Do not dismiss neuropathic symptoms as "normal postoperative pain"; they require specific evaluation for nerve pathology and targeted treatment with neuromodulating agents rather than just NSAIDs 1
• Do not order MR arthrography in the acute postoperative setting; standard MRI without contrast is sufficient and appropriate 1
• Do not delay urgent referral for red flag diagnoses, including septic arthritis, acute neurologic deficits, or fractures requiring fixation 1
• Do not overlook scapular dyskinesis assessment and treatment, as it is essential for resolution 5
• In throwing athletes, assess for spinal accessory nerve injury which can cause scapular winging 5
• Screen for and address common concurrent conditions like adhesive capsulitis or rotator cuff tendinopathy that may complicate treatment 5