What assessment and treatment approach should I use for a patient presenting with shoulder pain, considering their age, occupation, medical history, and symptoms?

Shoulder Pain Assessment for Orthopaedic Nurse Practitioners

Initial Imaging is Mandatory

Start with plain radiographs (minimum 3 views: anteroposterior, Grashey, and axillary or scapular Y) for every patient presenting with shoulder pain, regardless of whether the presentation is traumatic or atraumatic. 1, 2, 3

Critical Red Flags Requiring Urgent Action

Before proceeding with routine assessment, immediately identify and refer patients with:

• Fever with joint effusion (suspect septic arthritis—proceed directly to ultrasound or fluoroscopy-guided arthrocentesis) 1, 2, 3
• Acute neurologic deficits (requires immediate specialist evaluation) 2, 3
• Suspected cardiac or pulmonary pathology causing referred pain 2, 3
• Acute trauma with suspected fracture or dislocation (requires orthogonal radiographic views to confirm alignment) 1, 2

Age-Based Differential Diagnosis Framework

Patients Under 35 Years

Primary concerns are labral tears and glenohumeral instability. 1, 2, 3

Key historical features to elicit:

• Recurrent subluxation or "dead arm" sensation 2, 3
• Mechanical symptoms (clicking, catching, locking) 2, 3
• History of dislocation events 4
• Pain with overhead throwing or contact sports 4

Physical examination priorities:

• Apprehension test (positive suggests anterior instability) 4
• Relocation test (relief of apprehension with posterior humeral head pressure confirms instability) 4
• Load and shift test for quantifying translation 4

Patients 35 Years and Older

Primary concern is rotator cuff disease. 1, 2, 3

Key historical features to elicit:

• Pain with overhead activities 2, 4
• Night pain (classic for rotator cuff pathology) 2, 4
• Weakness with external rotation or abduction 2, 4
• Gradual onset without specific trauma 4

Physical examination priorities:

• Empty can test (supraspinatus) 4
• External rotation strength testing (infraspinatus/teres minor) 4
• Painful arc between 60-120 degrees of abduction (impingement) 4
• Clinical decision rule: pain with overhead activity + weakness on empty can test + weakness on external rotation + positive impingement sign = high probability of rotator cuff tear 4

Comprehensive Physical Examination Components

Essential Elements for Every Patient

• Assess tone, strength, soft tissue length changes, and joint alignment of the entire shoulder girdle 2, 3
• Range of motion in all planes (flexion, abduction, internal rotation, external rotation)—document both active and passive 2, 3, 4
• Restricted passive range of motion with diffuse pain suggests adhesive capsulitis (especially in patients with diabetes or thyroid disorders) 4

Specific Pathology Testing

Acromioclavicular joint pathology:

• Superior shoulder pain with AC joint tenderness 4
• Positive cross-body adduction test 4
• Order dedicated AC joint radiographic views if suspected 2

Biceps tendon pathology:

• Anterior shoulder pain 2
• Positive Speed's test (resisted forward flexion with elbow extended and forearm supinated) 2
• Positive Yergason's test (resisted supination with elbow flexed at 90 degrees) 2

Glenohumeral osteoarthritis:

• In patients >50 years: gradual pain and progressive loss of motion 4
• Crepitus with passive motion 4

Advanced Imaging Algorithm After Initial Radiographs

If Fracture Identified on Radiographs

Order CT without contrast to characterize fracture complexity, displacement, angulation, and aid surgical planning. 1, 2, 3

If Suspected Instability/Dislocation

Order MRI without IV contrast as the primary study. 2, 3

• Consider CT without contrast when bone loss assessment is critical for surgical planning (quantifying glenoid or humeral head bone loss) 1, 2, 3
• Look for Hill-Sachs deformity or bony Bankart lesions on radiographs 2
• Stryker notch view can be added to evaluate Hill-Sachs lesions 1

If Suspected Labral Tear

In acute trauma: order MRI without contrast (hemarthrosis provides natural joint distention). 2, 3

In subacute/chronic settings: MR arthrography is the reference standard. 1, 2, 3

• MR arthrography is generally recommended for patients <35 years because instability is predominantly related to labral pathology in this age group 1
• Direct MR arthrography with intra-articular gadolinium distends the joint and outlines labral and capsular structures 1

If Suspected Rotator Cuff Tear

Order either MRI without contrast or ultrasound—these are equivalent first-line studies, with choice depending on local expertise. 1, 2, 3

• For distinguishing full-thickness from partial-thickness tears, MR arthrography is recommended, particularly if abnormal signal extends from the undersurface of the tendon 1
• Ultrasound excels at rotator cuff assessment but has limited usefulness for deep soft tissues 1
• Post-rotator cuff repair with suspected retear: MRI without contrast, MR arthrography, and ultrasound are rated equally appropriate (rating 9/9) 1

If Suspected Septic Arthritis

Proceed directly to ultrasound-guided or fluoroscopy-guided arthrocentesis (both rated 9/9—equivalent). 1, 2, 3

• Aspiration is the procedure of choice; imaging is used for guidance, not diagnosis 1, 2
• MRI with and without contrast may be appropriate if clinical concern warrants, but arthrocentesis takes priority 1

Common Pitfalls to Avoid

• Never skip initial radiographs—they are essential for all presentations before proceeding to advanced imaging 1, 2, 3
• Do not misclassify acromioclavicular or glenohumeral dislocations on AP views alone—axillary or scapular Y views are vital 1, 2
• Perform radiographs upright when possible—shoulder malalignment can be underrepresented on supine films 1
• Do not dismiss neuropathic symptoms (electric shock sensations, allodynia, hyperpathia) as normal musculoskeletal pain—these require evaluation for nerve pathology and neuromodulating agents (gabapentin or pregabalin), not just NSAIDs 2, 3
• Correlate imaging findings with clinical presentation—treat the patient, not the images, as asymptomatic abnormalities are common on shoulder imaging 5, 6

Documentation Priorities

Document the following for every shoulder pain assessment:

• Mechanism of injury (if traumatic) or onset pattern (if atraumatic) 1
• Age (critical for differential diagnosis weighting) 1, 2, 3
• Occupation and activity level (overhead work, sports participation) 1, 2
• Presence or absence of red flags 2, 3
• Specific positive and negative examination findings with quantified strength and range of motion 2, 3, 4
• Radiographic findings from the mandatory 3-view series 1, 2, 3