Evaluation and Management of Left Shoulder Pain Without Chest Pain or Radiation
Begin with standard radiography including at least three views (AP in internal and external rotation, plus axillary or scapula-Y view) to exclude fracture, dislocation, or arthritis, then proceed to advanced imaging based on clinical findings and age. 1, 2
Initial Diagnostic Approach
Rule Out Referred Pain First
- Exclude cardiac, pulmonary, and visceral sources before assuming musculoskeletal etiology, as shoulder pain can mask serious systemic pathology including myocardial ischemia, gallbladder disease, or pulmonary conditions 3, 4
- Look specifically for: fever, shortness of breath, cough, pain with exertion, upper abdominal symptoms, or neurological deficits 3, 4
- Consider cervical spine pathology as a common extrinsic cause of shoulder pain 5
Standard Radiography (First-Line Imaging)
- Obtain three-view shoulder series upright: AP views in internal and external rotation plus axillary lateral or scapular Y view 1, 2, 6
- Radiography effectively demonstrates fractures, dislocations, shoulder malalignment, arthritis, and massive rotator cuff tears 1, 6, 7
- Add Grashey projection (30° posterior oblique) if glenohumeral joint pathology suspected 1
- Consider specialized views: Rockwood view for impingement, Westpoint view for bony Bankart lesions, Stryker notch view for Hill-Sachs deformity 1
Age-Based Advanced Imaging Algorithm (When Radiographs Noncontributory)
Age ≥35 Years: Suspect Rotator Cuff Pathology
- MRI shoulder without contrast (rating 9/9), MR arthrography (rating 9/9), or ultrasound (rating 9/9) are equivalent depending on local expertise 1
- MRI and ultrasound are preferred modalities for rotator cuff disorders 7
- Clinical decision rule supporting rotator cuff tear: pain with overhead activity, weakness on empty can and external rotation tests, positive impingement sign 7
- Ultrasound excels for rotator cuff and biceps tendon evaluation but has limited utility for deep structures and labrum 1
Age <35 Years: Suspect Labral Tear or Instability
- MR arthrography is the preferred modality (rating 9/9) for labral tears and instability 1
- MRI without contrast (rating 7/9) acceptable with optimized equipment 1
- Look for history of dislocation/subluxation events, positive apprehension and relocation tests 7
Specific Clinical Scenarios
Suspected Bursitis or Biceps Tenosynovitis:
- MRI without contrast (rating 9/9) or ultrasound (rating 9/9) are equivalent 1
Suspected Adhesive Capsulitis:
- Clinical diagnosis: diffuse shoulder pain with restricted passive range of motion 7
- Associated with diabetes and thyroid disorders 7
- MRI, MR arthrography, or ultrasound (all rating 9/9) if diagnosis unclear 1
Acromioclavicular Joint Pathology:
- Superior shoulder pain, AC joint tenderness, painful cross-body adduction test 7
- Standard radiography usually sufficient 6
Critical Pitfalls to Avoid
- Do not assume musculoskeletal origin without excluding systemic causes, particularly cardiac, pulmonary, and visceral pathology 3, 4
- Obtain orthogonal views to prevent misclassification of AC and glenohumeral dislocations 2
- Do not rely on ultrasound alone for nonspecific shoulder pain, as 40% may show no significant pathology and it is inferior to MRI for labral, osseous, and some rotator cuff pathology 1
- Refer immediately to orthopedics for unstable/displaced fractures, neurological deficits, or joint instability 2