What is the appropriate workup and management for an adult patient with no significant past medical history presenting with shoulder, neck, and back pain?

Workup and Management of Shoulder, Neck, and Back Pain in Adults

Initial Clinical Assessment

Begin with a focused history and physical examination to identify "red flags" that mandate immediate imaging or specialist referral, as routine imaging without these indicators does not improve outcomes and may lead to unnecessary interventions. 1

Critical Red Flags Requiring Urgent Evaluation

• Fever with new or worsening pain suggests vertebral osteomyelitis or infection 1
• Elevated ESR or CRP with pain warrants consideration of infection or inflammatory conditions 1
• Concurrent bloodstream infection or endocarditis with spinal pain 1
• Severe or progressive neurologic deficits (weakness, numbness, bowel/bladder dysfunction) 1
• History of cancer with new spinal pain suggests metastatic disease 1
• Age >50 years with constitutional symptoms (unexplained weight loss, night sweats) 1
• History of osteoporosis or chronic steroid use increases fracture risk 1
• Recent trauma in any age group, particularly elderly patients where minimal trauma can cause fractures 1

Essential History Components by Region

Shoulder Pain:

• Document exact mechanism of injury, time since onset, and whether pain is traumatic or atraumatic 1, 2
• Identify pain location: anterior shoulder suggests rotator cuff/biceps pathology; superior shoulder indicates AC joint disease; scapular region may indicate cervical spine referral 1, 3, 2
• Ask about instability symptoms (shoulder "giving way") particularly in patients under 40 years 1, 2
• Screen for neurological symptoms (numbness, tingling, weakness radiating down arm) suggesting cervical radiculopathy 3, 2

Neck Pain:

• Distinguish acute (<6 weeks) from chronic presentations 1
• Assess for radicular symptoms following dermatomal distributions (C5-C8) 1, 3
• Document aggravating factors and radiation patterns 1

Back Pain:

• Determine duration and presence of radiculopathy or spinal stenosis symptoms 1
• Assess for risk factors: IV drug use, immunosuppression, recent instrumentation 1

Imaging Strategy

When Imaging is NOT Indicated

Do not routinely obtain imaging in patients with nonspecific low back pain, acute neck pain (<6 weeks), or shoulder pain without red flags or trauma. 1

• Routine imaging does not improve outcomes and identifies abnormalities poorly correlated with symptoms 1
• Most acute musculoskeletal pain resolves within 4-6 weeks with conservative management 1

When Imaging IS Indicated

Shoulder Pain:

• Plain radiographs (3 views minimum: AP internal/external rotation, axillary or scapular Y) are the mandatory first step for any traumatic shoulder pain or suspected fracture 1
• MRI without contrast is preferred for suspected rotator cuff tears, labral pathology, or when radiographs are normal but clinical suspicion remains high 1, 4
• Ultrasound is an excellent alternative if local expertise available, particularly for rotator cuff evaluation 4

Neck Pain:

• MRI cervical spine without contrast is the preferred study when red flags present or radiculopathy suspected 1, 3
• Plain radiographs may be obtained first to assess gross structural abnormalities, though they cannot visualize disc herniations 1, 3
• Immediate MRI or CT required for severe/progressive neurologic deficits, suspected infection, or cancer with cord compression 1

Back Pain:

• MRI (preferred) or CT only if severe/progressive neurologic deficits, suspected serious underlying condition (infection, cancer, cauda equina), or persistent symptoms with radiculopathy/stenosis in surgical candidates 1
• Plain radiographs reasonable for suspected vertebral compression fracture in high-risk patients (osteoporosis, steroid use, age >65) 1

Laboratory Testing

Obtain the following when infection or inflammatory conditions suspected:

• Two sets of blood cultures (aerobic and anaerobic) before antibiotics if vertebral osteomyelitis suspected 1
• ESR and CRP as baseline inflammatory markers 1
• Brucella serology in endemic areas for subacute presentations 1
• PPD or interferon-γ release assay for subacute cases suggesting tuberculous osteomyelitis 1

Initial Management Algorithm

Conservative Management (No Red Flags Present)

For Shoulder Pain (Age >35-40 years):

• Acetaminophen first-line: 2 caplets every 8 hours, maximum 6 caplets/24 hours, not exceeding 10 days 4, 5
• Topical agents (methyl salicylate, capsaicin, menthol) for mild-moderate pain 4
• NSAIDs cautiously if acetaminophen fails, recognizing high risk in elderly for GI/renal toxicity 4
• Physical therapy: Range of motion exercises focusing on external rotation and abduction, rotator cuff strengthening once pain-free motion achieved 4, 2
• Avoid overhead pulleys which may worsen pain 4

For Neck/Back Pain:

• Reassurance and continuation of normal activities as tolerated 1
• Acetaminophen or NSAIDs for pain control 1
• Muscle relaxants (cyclobenzaprine 5-10 mg TID) may be added for acute muscle spasm, though drowsiness is common 6
• Re-evaluate at 4-6 weeks if no improvement 1

When to Escalate Care

Immediate specialist referral required for:

• Unstable or significantly displaced fractures on imaging 1, 4
• Shoulder joint instability 1, 4
• Suspected massive rotator cuff tears requiring expedited repair 1, 4
• Neurological deficits 4
• Clinical suspicion of septic arthritis 1, 4
• Cauda equina syndrome 1
• Spinal cord compression from cancer or infection 1

Consider MRI and specialist consultation for:

• Persistent symptoms beyond 4-6 weeks despite conservative management 1
• Radiculopathy symptoms in surgical candidates 1
• Confirmed cervical radiculopathy with neuropathic pain features (consider pregabalin 300-600 mg daily in divided doses) 3

Critical Pitfalls to Avoid

• Do not assume absence of trauma means absence of fracture in elderly patients, as osteoporotic fractures occur with minimal trauma 4, 2
• Do not delay imaging when red flags present, as delayed diagnosis of infection or cancer worsens outcomes 1
• Do not prescribe NSAIDs long-term in elderly given high frequency of adverse events 4
• Do not assume neck pain is "muscle tension" without ruling out cervical radiculopathy or structural pathology 3, 7
• Avoid unnecessary radiation exposure in young women, as lumbar spine radiographs (2 views) equal one year of daily chest X-rays 1