Is an x-ray appropriate for a non-surgical candidate with chronic right shoulder pain, severe hand pain, numbness, and slight swelling?

X-Ray Imaging for Chronic Shoulder Pain with Hand Symptoms

Yes, x-ray imaging is appropriate and should be obtained for both the shoulder and hand in this clinical scenario. The combination of chronic shoulder pain with new severe hand pain, numbness, and swelling requires radiographic evaluation to rule out fracture, arthropathy, and other osseous pathology before proceeding to advanced imaging.

Initial Imaging Approach

Shoulder Radiography

• Standard three-view shoulder radiographs are the appropriate first-line imaging study for chronic shoulder pain, including anteroposterior (AP) views in internal and external rotation plus an axillary or scapular-Y view 1, 2, 3.
• Radiographs can identify fractures, arthritis, calcific tendinitis, bone lesions, and other osseous abnormalities that may be contributing to symptoms 4.
• Even in chronic shoulder conditions, plain radiography remains essential as the initial study before considering advanced imaging 5, 4.

Hand Radiography

• X-rays of the hand are appropriate as the initial imaging study for the new severe hand pain, numbness, and swelling 1.
• Hand radiographs can identify fractures, arthritis, bone lesions, and other osseous pathology that may explain the acute symptoms 1.
• The ACR Appropriateness Criteria specifically addresses chronic hand pain scenarios where radiographs serve as the baseline study before determining need for additional imaging 1.

Clinical Reasoning for This Patient

Why Both Areas Need Imaging

• The patient presents with two distinct anatomical complaints: chronic shoulder pain AND new severe hand pain with numbness and swelling 1.
• These symptoms may represent:
  • Separate pathologies requiring independent evaluation
  • Referred pain patterns (though hand numbness and swelling suggest local pathology)
  • Neurologic compromise affecting the upper extremity
  • Systemic inflammatory or rheumatologic conditions

Addressing the Hand Symptoms Specifically

• Severe hand pain with numbness and swelling represents a change in clinical status that warrants investigation 1.
• Numbness suggests possible nerve entrapment (carpal tunnel syndrome, ulnar nerve compression) or neurologic compromise 1.
• Swelling indicates possible inflammatory arthropathy, infection, fracture, or soft tissue injury 1.
• The combination of these symptoms in a non-surgical candidate makes it critical to identify treatable causes that don't require surgery 1.

Next Steps After Radiography

If Radiographs Are Normal or Show Nonspecific Findings

For the shoulder:

• MRI shoulder without contrast or ultrasound of the shoulder are usually appropriate next imaging studies for chronic shoulder pain with noncontributory radiographs 1.
• These modalities are equivalent for evaluating rotator cuff pathology, though MRI may be preferred if multiple intra-articular pathologies are suspected 1.

For the hand:

• Ultrasound of the hand is highly appropriate if radiographs are normal or show only nonspecific arthritis, particularly for evaluating tendinopathy, tenosynovitis, nerve entrapment (carpal tunnel syndrome), and soft tissue pathology 1.
• Ultrasound changed clinical management in 76% of patients referred from hand surgeons and was contributory in 67% of non-trauma cases 1.
• MRI hand without contrast may be appropriate if ultrasound is inconclusive or unavailable, though it has limited benefit for nonspecific pain 1.

If Radiographs Show Specific Pathology

For fractures:

• CT without contrast is usually appropriate for complex fracture characterization if surgical planning is needed 1, 3.
• However, since this patient is not a surgical candidate, CT may be less critical unless fracture management requires detailed anatomic information for conservative treatment 1.

For arthropathy:

• Clinical correlation with radiographic findings guides treatment decisions 1, 6.
• Many patients have radiographic abnormalities that are asymptomatic, so correlation with physical examination is essential 6.

Critical Pitfalls to Avoid

• Do not skip radiography in favor of advanced imaging even in chronic cases, as plain films may reveal unexpected fractures, tumors, or other pathology that changes management 4, 7.
• Do not assume hand symptoms are referred from the shoulder without evaluating the hand directly—numbness and swelling suggest local pathology requiring independent assessment 1.
• Do not order MRI as the first study without obtaining baseline radiographs, as this represents overutilization and may miss osseous pathology best seen on plain films 4, 7.
• Recognize that "not a surgical candidate" status makes accurate diagnosis even more important, as conservative management options depend on knowing the specific pathology 1.

Practical Implementation

1. Order shoulder radiographs (3 views: AP internal rotation, AP external rotation, and axillary or scapular-Y) 1, 2, 3
2. Order hand radiographs (standard views based on location of symptoms) 1
3. Correlate imaging findings with physical examination, particularly assessing for:
   • Shoulder deformity, range of motion limitations, rotator cuff strength 1
   • Hand/wrist nerve compression signs (Tinel's, Phalen's), joint swelling distribution, tendon integrity 1
4. If radiographs are noncontributory, proceed to ultrasound for both shoulder and hand as the next most appropriate study, given its diagnostic utility and lack of radiation 1