How should I perform a systematic shoulder assessment, including history, physical examination, imaging, laboratory tests, and initial management?

Systematic Shoulder Assessment

History Taking

Begin by documenting the exact mechanism of injury—including how any fall occurred, height of fall, landing position, and whether the injury was work-related—as this immediately separates traumatic from atraumatic pathology. 1, 2

Injury Mechanism and Timing

• Record the precise time of injury and symptom evolution, distinguishing acute presentations (<2 weeks) from chronic (>6 months) 2
• Determine whether pain is directly attributed to a specific traumatic event or developed insidiously 1, 2
• Document any previous shoulder injuries including prior dislocations, fractures, or rotator cuff repairs 2

Pain Localization and Character

• Anterior shoulder pain suggests rotator cuff or biceps pathology 2
• Superior shoulder pain indicates acromioclavicular joint disease 2
• Scapular region pain may indicate referred pain from cervical spine or rotator cuff 2
• Document pain severity using standardized scales and identify specific aggravating factors (overhead activities, cross-body adduction, throwing motions) and alleviating factors 2

Age-Specific History Focus

• For patients over 35-40 years: prioritize questions about rotator cuff disease, degenerative changes, and arthritis 2
• For patients under 35 years: focus on instability, labral tears, and sports-related injuries 2

Functional Limitations and Instability

• Ask specifically about any sensation of the shoulder "giving way" or feeling unstable during activities 2
• Document any history of shoulder dislocation or subluxation events, particularly in younger patients 2

Red Flag Screening

• Screen for neurological symptoms: numbness, tingling, weakness, or radiation down the arm suggesting cervical radiculopathy 2
• Ask about systemic symptoms including fever, chills, or constitutional symptoms that may indicate septic arthritis 2, 3
• Palpate radial and ulnar arterial pulses; absence of a pulse after high-energy trauma or dislocation requires immediate vascular imaging 2

Critical Pitfall

Do not assume absence of trauma means absence of fracture—osteoporotic fractures in elderly patients can occur with minimal or unrecognized trauma. 2

Physical Examination

Inspection and Palpation

• Assess for loss of symmetry, visible deformity, or muscle atrophy 4
• Localize tenderness to specific anatomic structures (acromioclavicular joint, bicipital groove, greater tuberosity) 4

Range of Motion Assessment

• Test both active and passive range of motion in all planes—limited and painful passive motion suggests adhesive capsulitis, while preserved passive motion with painful/weak active motion suggests rotator cuff pathology 2
• Assess abduction, forward flexion, internal rotation (arm behind back), and external rotation 2

Specific Provocative Tests

For Rotator Cuff Pathology

• Empty can test (supraspinatus): 92% sensitive when combined with Hawkins' test 2
• Hawkins' test: 92% sensitive for impingement 2
• Neer's test: 88% sensitive for impingement 2
• Test external rotation strength (infraspinatus/teres minor) and internal rotation strength (subscapularis) 2
• Pain with internal rotation and arm behind back specifically implicates the subscapularis tendon 2

For Instability

• Apprehension and relocation tests for anterior instability (particularly relevant in patients under 40 years) 2

For Scapular Dyskinesis

• Assess scapular coordination during arm elevation—poor scapular mechanics may be both cause and effect of rotator cuff pathology 2

Neurovascular Examination

• Palpate radial and ulnar pulses bilaterally 2
• Test sensation in axillary, radial, median, and ulnar nerve distributions 2
• Assess motor function of major nerve distributions 2

Red Flag Assessment

• Evaluate for signs of complex regional pain syndrome (CRPS) in patients with chronic post-traumatic shoulder pain lacking clear etiology—early identification prompts multidisciplinary referral 2

Imaging

Initial Imaging: Radiography

Radiography is the mandatory first imaging study for all shoulder evaluations, consisting of at least three views: anteroposterior (AP) projections in internal and external rotation plus an axillary or scapula-Y view, performed with the patient upright. 1, 5, 3

• The axillary or scapula-Y view is essential—AP views alone can misclassify acromioclavicular and glenohumeral dislocations 1, 5, 3
• Upright positioning is critical because supine radiography underrepresents shoulder malalignment 1, 5
• Radiography effectively delineates bony anatomy to assess for fracture and shoulder alignment, which are the two primary concerns in acute traumatic shoulder pain 1

Advanced Imaging Based on Clinical Findings

For Suspected Rotator Cuff Pathology (Age >35 Years)

After noncontributory radiographs, MRI without contrast or ultrasound are equally appropriate (both rated 9/9 appropriateness), depending on local expertise. 3

• Ultrasound has 85% sensitivity and 90% specificity for rotator cuff and biceps tendon pathology when performed by experienced operators 2
• Ultrasound allows dynamic assessment during arm movement and is cost-effective 2
• MRI without contrast is effective in diagnosing most traumatic soft-tissue pathologies including labral, rotator cuff, and glenohumeral ligament injuries 1

For Suspected Labral Tear/Instability (Age <35 Years)

MR arthrography is the gold standard (rated 9/9 appropriateness) for evaluating intra-articular pathology such as labral tears and capsular injuries. 1, 3

• MR arthrography is superior to standard MRI for diagnosing SLAP tears, labroligamentous injuries, and partial rotator cuff tears 1
• MR arthrography is comparable to CT in evaluating traumatic osseous lesions such as bony Bankart and Hill-Sachs lesions 1

For Fracture Characterization

CT is superior to radiography for characterizing fracture patterns and is particularly valuable for preoperative planning of complex fractures. 1, 3

• CT is better able than radiography to delineate fracture planes but is inferior to MRI for diagnosing soft-tissue injuries 1

For Suspected Septic Arthritis

Ultrasound or fluoroscopic-guided arthrocentesis (rated 9/9 appropriateness) with aspiration and fluid analysis is essential for diagnosis. 3

Critical Imaging Pitfalls

• Never rely on AP view alone—orthogonal views are essential to prevent missed dislocations 5
• Do not skip radiographs and proceed directly to MRI or ultrasound, even when soft tissue pathology is suspected 5
• Ensure adequate views are obtained; inadequate imaging leading to missed fracture components is a common error 5

Laboratory Tests

When to Order Laboratory Studies

• Order laboratory tests when septic arthritis is suspected: obtain synovial fluid analysis including cell count with differential, Gram stain, and culture 3
• Consider inflammatory markers (ESR, CRP) when inflammatory arthropathy is in the differential 2
• Laboratory tests are not routinely indicated for mechanical shoulder pain or rotator cuff pathology 2

Initial Management

Conservative Management for Rotator Cuff Pathology

Complete rest from aggravating activities until the patient is asymptomatic, followed by a structured rehabilitation program. 2

Phase 1: Pain Control and Rest

• Complete rest from aggravating activities 2
• NSAIDs for acute pain management 2
• Consider intra-articular corticosteroid injections (Triamcinolone) for more severe cases 2
• Ice, heat, and soft tissue massage as adjunctive modalities 2

Phase 2: Range of Motion Restoration

• Improve range of motion through stretching and mobilization, focusing especially on external rotation and abduction to prevent frozen shoulder 2
• Avoid overhead pulley exercises, which encourage uncontrolled abduction and can worsen rotator cuff pathology 2

Phase 3: Strengthening

• Begin rotator cuff and scapular stabilizer strengthening only once pain-free motion is achieved 2
• Consider functional electrical stimulation (FES) to improve shoulder lateral rotation 2
• Lateral rotation exercises are particularly important as lateral rotation is the factor most significantly related to onset of shoulder pain 2

Return to Activity

• Allow return to activities only after completing a functional, progressive, and individualized program over 1 to 3 months without evidence of symptoms 2

Management for Adhesive Capsulitis

• Aggressive stretching and mobilization focusing on external rotation and abduction 2
• Serial casting for contractures that interfere with function 2
• Avoid overhead pulley exercises 2

Surgical Referral Indications

Unstable or significantly displaced fractures require acute surgical management. 1

• Acute shoulder dislocations requiring reduction 1
• Full-thickness rotator cuff tears in appropriate surgical candidates (though many can undergo conservative management first) 1
• Recurrent instability despite conservative management 2