What is the appropriate work‑up for a right‑shoulder injury that began two weeks ago after lifting?

Work-Up for Right Shoulder Injury from Lifting 2 Weeks Ago

Begin with three-view radiographs (AP internal rotation, AP external rotation, and axillary or scapular-Y view) performed upright, followed by targeted physical examination maneuvers to guide the need for advanced imaging based on clinical findings. 1, 2

Initial Imaging: Radiographs First

• Order upright radiographs with minimum 3 views: AP internal rotation, AP external rotation, and axillary or scapular-Y view 1, 2
• The upright positioning is critical because shoulder malalignment can be significantly underrepresented on supine films 1, 2
• Never rely on AP views alone—acromioclavicular and glenohumeral joint dislocations can be completely missed without the orthogonal axillary or scapular-Y view 1, 2
• Radiographs effectively demonstrate fractures, joint alignment abnormalities, calcific tendinitis, and acromioclavicular joint pathology 1

Focused Physical Examination

After obtaining radiographs, perform these specific examination maneuvers to narrow your differential:

For Rotator Cuff Tears (Most Common in Lifting Injuries)

• Test active abduction above 90°: Inability to abduct above 90° has 84% sensitivity and 71% specificity for full-thickness rotator cuff tears in acute injuries 3
• Assess external rotation strength (small finger test): 66% sensitivity and 86% specificity for infraspinatus tears 3
• Combining both tests increases sensitivity above 90% and diagnostic odds ratio above 22 for detecting full-thickness supraspinatus/infraspinatus tears 3
• The Jobe test (empty can test) has 52.6% sensitivity but 82.4% specificity for full-thickness supraspinatus tears 4
• The lag sign is highly sensitive (97%) and specific (93%) for combined full-thickness supraspinatus and infraspinatus tears 4

For Impingement Syndrome

• Neer sign: 75% sensitivity for subacromial impingement 4
• Hawkins-Kennedy test: 80% sensitivity for subacromial impingement 4
• Painful arc test: 80% specificity for subacromial impingement 4

For Acromioclavicular Joint Injury

• Cross-body adduction test: 77% sensitivity and 79% specificity for AC joint pathology 4

Advanced Imaging Algorithm (If Radiographs Are Normal)

If radiographs are noncontributory but clinical suspicion remains high based on physical examination:

For Suspected Rotator Cuff Pathology

• Ultrasound is generally preferred over MRI for chronic rotator cuff pain evaluation 1
• Ultrasound excels at assessing rotator cuff injuries but has limited usefulness for deep soft-tissue structures 5
• MRI without contrast is rated 9/9 by the American College of Radiology for suspected bursitis or biceps tenosynovitis, with ultrasound equivalent for this indication 1

For Suspected Labral Tears or Instability

• MR arthrography is rated 9/9 by the American College of Radiology for suspected labral tears or instability 1
• MRI without contrast is rated 7/9 if optimized imaging equipment is available 1
• The apprehension test has a hazard ratio of 2.96 for anterior shoulder instability 4

For Complex Fracture Characterization

• CT is superior to radiography for characterizing fracture patterns and preoperative planning 5, 2
• CT is considered inferior to MRI for diagnosing essentially all soft-tissue shoulder injuries 5

Clinical Decision Points at 2 Weeks Post-Injury

At 2 weeks, you need to determine if this injury requires surgical consideration or can continue conservative management:

Injuries Requiring Surgical Consideration

• Unstable or significantly displaced fractures (visible on radiographs) 2
• Joint instability confirmed on examination 2
• Traumatic massive rotator cuff tears may require expedited surgical repair 2

Injuries Amenable to Conservative Management

• Most soft-tissue injuries including labral tears and rotator cuff tears can undergo conservative management before considering surgery 5, 2
• Low-grade acromioclavicular separations 5

Critical Pitfalls to Avoid

• Do not skip the axillary or scapular-Y view—posterior dislocations, AC joint separations, and subtle malalignment will be missed on AP views alone 1, 2
• Do not obtain supine radiographs—shoulder malalignment is significantly underrepresented compared to upright imaging 1, 2
• Do not order MRI as initial imaging—radiographs must come first to rule out fractures and malalignment, which are the primary concerns in traumatic shoulder injuries 5, 2
• In patients over 40 years with acute shoulder trauma and negative radiographs, maintain high suspicion for rotator cuff tears, as they may easily be missed 3