What is the appropriate physical assessment and initial management for a patient presenting with shoulder pain, considering their age, sex, past medical history, and potential underlying conditions?

Physical Assessment for Shoulder Pain

Begin with a comprehensive clinical history focusing on mechanism of injury, followed by a systematic physical examination that includes inspection, palpation, range of motion testing, and provocative maneuvers, with radiography (minimum 3 views including AP internal/external rotation plus axillary or scapular-Y view) as the initial imaging modality. 1

Clinical History - Key Elements to Elicit

Mechanism of injury is the single most important historical element as it helps distinguish between traumatic injuries requiring acute surgical management versus those amenable to conservative treatment 1.

• Traumatic onset: Assess for fractures (clavicle, scapula, proximal humerus), rotator cuff tears, acromioclavicular ligament injuries, or labroligamentous complex injuries 1
• Patient demographics: Young adult males have higher incidence of traumatic shoulder injuries; age >50 years suggests glenohumeral osteoarthritis; age <40 years with instability history suggests glenohumeral instability 1, 2
• Associated conditions: Screen for diabetes and thyroid disorders (associated with adhesive capsulitis) 2
• Pain characteristics: Overhead activity pain suggests rotator cuff pathology; superior shoulder pain suggests acromioclavicular osteoarthritis 2
• History of dislocation/subluxation events: Indicates glenohumeral instability 2

Physical Examination - Systematic Approach

Inspection and Palpation

• Visual assessment: Look for asymmetry, muscle atrophy, swelling, or deformity 3, 4
• Palpation: Assess for acromioclavicular joint tenderness (suggests AC osteoarthritis) and point tenderness over specific structures 2, 3

Range of Motion Testing

• Passive range of motion: Restricted passive ROM with diffuse pain indicates adhesive capsulitis 2
• Active range of motion: Compare to contralateral side; gradual pain and loss of motion in patients >50 years suggests glenohumeral osteoarthritis 2
• Perform upright, not supine: Shoulder malalignment can be significantly underrepresented on supine examination 5

Provocative Testing - Specific Maneuvers

For rotator cuff pathology (use clinical decision rule):

• Empty can test: Weakness suggests rotator cuff tear 2
• External rotation strength test: Weakness suggests rotator cuff tear 2
• Impingement sign: Positive test combined with overhead activity pain and weakness on above tests strongly suggests rotator cuff tear 2

For glenohumeral instability:

• Apprehension test: Positive in patients <40 years with instability history 2
• Relocation test: Positive result confirms glenohumeral instability 2

For acromioclavicular pathology:

• Cross-body adduction test: Pain indicates AC osteoarthritis 2

Additional Examination Components

• Cervical spine evaluation: Rule out referred pain 3, 4
• Scapular assessment: Evaluate scapular positioning and movement 6, 3
• Sensorimotor examination: Complete upper extremity neurologic assessment 3
• Elbow evaluation: Rule out referred pathology 3

Initial Imaging - When and What to Order

Radiographs are the preferred initial diagnostic modality for acute shoulder pain because they delineate shoulder malalignment and most fractures 1.

Standard Radiographic Protocol

Order minimum 3 views with 2 orthogonal:

• AP view in internal rotation 5, 7
• AP view in external rotation 5, 7
• Axillary lateral view OR scapular-Y view (essential - cannot rely on AP views alone) 1, 5, 7

Critical Pitfall to Avoid

Never rely on AP views alone - acromioclavicular and glenohumeral joint dislocations can be completely missed or misclassified without the orthogonal view 1, 5, 7. Posterior dislocations, AC joint separations, and subtle malalignment require the axillary or scapular-Y view for detection 5.

Technical Consideration

• Perform radiographs upright, not supine - shoulder malalignment is significantly underrepresented on supine imaging 5, 7

Management Decision Points Based on Assessment

Injuries requiring acute surgical consideration:

• Unstable or significantly displaced fractures 1
• Joint instability 1
• Consider patient age, comorbidities, and activity level in surgical decision-making 1

Injuries amenable to initial conservative management:

• Soft tissue injuries including labral tears and rotator cuff tears 1, 7
• Exception: Traumatic massive rotator cuff tears may require expedited surgical repair for optimal functional outcomes 1

Advanced Imaging - When Radiographs Are Noncontributory

If 3-view radiographs are normal but clinical suspicion remains:

• Suspected labral tear/instability (especially age <35): MR arthrography is gold standard 7
• Suspected rotator cuff pathology: MRI without contrast or ultrasound (both equally appropriate, depending on local expertise) 7
• Suspected septic arthritis: Ultrasound or fluoroscopic-guided arthrocentesis with fluid analysis 7
• Complex fracture characterization: CT for preoperative planning 7