What's the best diagnostic and management approach for neck to shoulder pain, including the use of imaging like X-rays, MRI (Magnetic Resonance Imaging), or CT (Computed Tomography) scans?

Imaging Approach for Neck-to-Shoulder Pain

Start with plain radiographs of the shoulder (anteroposterior views in internal and external rotation plus axillary or scapula-Y view) as your initial imaging study, followed by MRI without contrast if radiographs are negative or nondiagnostic. 1

Initial Imaging Strategy

Plain Radiography First

• Obtain shoulder radiographs as the most appropriate initial study for neck-to-shoulder pain, particularly when trauma or shoulder pathology is suspected 1
• Include minimum three views: anteroposterior in internal rotation, anteroposterior in external rotation, and axillary or scapula-Y view 1
• Perform radiographs upright rather than supine, as shoulder malalignment can be underrepresented on supine imaging 1
• Axillary or scapula-Y views are vital because acromioclavicular and glenohumeral dislocations can be misclassified on AP views alone 1

When to Add Cervical Spine Imaging

• Obtain five-view cervical spine radiographs (anteroposterior, lateral, open-mouth, and both oblique views) if clinical examination suggests cervical spine pathology as the pain source 2
• Consider that shoulder impingement can present as neck pain near the superomedial scapula, making shoulder evaluation critical even when pain localizes to the neck 3

Advanced Imaging After Negative Radiographs

MRI Without Contrast - Primary Advanced Study

• Order MRI shoulder without IV contrast as the most appropriate next study when radiographs are negative or nondiagnostic and pain is nonlocalized 1
• MRI effectively diagnoses soft-tissue pathologies including labral tears, rotator cuff injuries, and glenohumeral ligament injuries 1
• In acute trauma settings, posttraumatic joint effusion or hemarthrosis typically provides sufficient joint distention without requiring arthrography 1
• For suspected rotator cuff tears specifically, MRI without contrast and ultrasound are equivalent alternatives—choose based on local expertise and patient factors 1, 4

Ultrasound as Alternative

• Ultrasound is comparable to MRI for evaluating full-thickness rotator cuff tears and rotator cuff atrophy 1
• However, ultrasound is inferior to MRI for partial-thickness rotator cuff tears and intra-articular pathology 1
• Prefer MRI over ultrasound when large body habitus, restricted range of motion from acute pain, or suspicion of other intra-articular pathologies (such as labral tears) exists 1

CT Scanning - Limited Role

When CT is Appropriate

• Use CT without IV contrast when radiographs demonstrate fractures requiring detailed characterization of fracture planes 1
• CT is superior to radiography for characterizing fracture patterns but inferior to MRI for essentially all soft-tissue shoulder injuries 1
• Consider CT when MRI assessment of bone loss is limited or when MRI is contraindicated 1

CT Limitations

• Do not use CT as initial imaging—radiography adequately diagnoses displaced fractures and shoulder malalignment, which are the primary concerns in initial assessment 1

Specialized Advanced Imaging

MR Arthrography

• MR arthrography is considered the gold standard for imaging traumatic shoulder pain and superior to noncontrast MRI for intra-articular pathology 1
• Particularly useful for diagnosing SLAP tears, labroligamentous injuries, and partial rotator cuff tears 1
• However, in acute trauma settings with joint effusion present, the invasive nature makes MR arthrography suboptimal compared to noncontrast MRI 1
• Reserve MR arthrography for subacute or chronic settings when glenohumeral joint effusion is too small to provide sufficient joint distention on standard MRI 1

CT Arthrography

• CT arthrography is comparable to MR arthrography for diagnosing Bankart, Hill-Sachs, SLAP, and full-thickness rotator cuff tears 1
• Inferior to MR arthrography for partial-thickness rotator cuff tears, including bursal-sided tears 1
• Use CT arthrography only when MRI is contraindicated 1

Clinical Examination Considerations

Key Diagnostic Pitfall

• Recognize that shoulder impingement can present as chronic neck pain near the superomedial scapula rather than typical shoulder pain 3
• Test for positive impingement sign with pain referred to the neck, and consider diagnostic/therapeutic subacromial injection if clinical suspicion is high 3
• Over 80% of practitioners examine the neck when patients present with shoulder pain, most commonly using active range-of-movement testing and neurological examination 5

Cervical Spine Evaluation

• Perform MRI of the cervical spine in patients with chronic neurologic signs or symptoms, regardless of radiographic findings 2
• If contraindication to MRI exists, use CT myelography 2
• For traumatic cervical spine injury with blunt trauma and neck pain, CT has 88.6% sensitivity (99% specificity), while MRI identifies injuries missed by CT in symptomatic patients 6

Radiation Safety

• Consider that pediatric patients are at inherently higher risk from radiation exposure due to organ sensitivity and longer life expectancy 1
• Plain radiography and MRI avoid radiation exposure, making them preferable to CT when diagnostic yield is equivalent 1