What is the next step in management of a patient with shoulder pain who has no red‑flag symptoms (e.g., severe trauma, neurovascular deficit, fever, or night pain that awakens them)?

Next Step in Management of Shoulder Pain Without Red Flags

For a patient with shoulder pain and no red flag symptoms, initiate conservative management immediately without imaging—specifically, begin physical activity/exercise therapy combined with patient education, and avoid ordering radiographs, MRI, or other imaging studies as they do not influence management or improve clinical outcomes in this setting. 1, 2

Initial Assessment Without Imaging

• Do not order imaging studies (radiographs, MRI, CT, or ultrasound) in the absence of red flags, as imaging is not indicated and does not change management or improve outcomes. 1, 2

• The American College of Radiology explicitly states that radiographs "are often not needed in the acute setting in the absence of red flag symptoms and do not influence management or improve clinical outcome." 1

• This recommendation applies across all musculoskeletal pain conditions, including shoulder pain, where imaging without red flags leads to overdiagnosis of incidental findings that do not correlate with symptoms. 1, 2

Physical Examination Components

Perform a focused physical examination that includes: 1, 2

• Range of motion assessment in all planes (flexion, abduction, internal/external rotation) 1
• Neurological screening to rule out radiculopathy or referred pain from cervical spine 1, 2
• Strength testing of rotator cuff muscles and scapular stabilizers 1
• Palpation for specific tenderness over acromioclavicular joint, biceps tendon, and rotator cuff insertion 1

Conservative Management Protocol

Implement the following evidence-based interventions immediately: 1

Physical Activity and Exercise (Primary Treatment)

• Prescribe structured exercise therapy as the cornerstone of treatment—this is a "should do" recommendation across all high-quality musculoskeletal pain guidelines. 1
• Exercise should be progressive and individualized based on examination findings, targeting range of motion, strengthening, and functional activities. 1

Patient Education (Essential Component)

• Provide education about the condition, expected prognosis (most shoulder pain improves with conservative care), and self-management strategies. 1
• Education should address psychosocial factors and reassure patients about the benign nature of their condition in the absence of red flags. 1

Manual Therapy (Adjunct Only)

• Use manual therapy only as an adjunct to exercise and education, not as standalone treatment. 1
• Manual therapy alone is insufficient and should always be combined with active interventions. 1

Monitoring and Reassessment

• Evaluate patient progress using validated outcome measures (e.g., DASH score, pain scales, functional assessments). 1

• Reassess at 4-6 weeks to determine response to conservative management. 1

• Consider imaging only if:

  • Red flags develop during the course of treatment 1, 2
  • There is unsatisfactory response to conservative care after 6-8 weeks 1, 3
  • Unexplained progression of signs and symptoms occurs 1
  • The imaging result would change management (e.g., considering surgical intervention) 1

Common Pitfalls to Avoid

• Do not order "routine" shoulder radiographs or MRI just because the patient has pain—this leads to unnecessary findings that create patient anxiety and do not improve outcomes. 1, 2

• Do not assume imaging abnormalities are causative if imaging is eventually obtained—degenerative changes are present in 85% of asymptomatic individuals over 30 years old and do not correlate with symptoms. 3

• Do not delay conservative treatment while waiting for imaging results, as this prolongs disability without benefit. 1

• Do not use manual therapy as monotherapy—it must be combined with exercise and education to be effective. 1

When to Consider Advanced Management

Refer for surgical evaluation only if: 1

• Conservative management fails after adequate trial (typically 6-8 weeks minimum) 1, 3
• Progressive neurological deficits develop 3
• Red flags emerge during follow-up 1, 2

The key principle is that unless specifically indicated by red flags or failed conservative treatment, evidence-informed non-surgical care should always precede surgical consultation. 1