What is the appropriate evaluation and management for a patient presenting with left shoulder pain of two weeks' duration?

Evaluation and Management of Left Shoulder Pain (2 Weeks Duration)

Start with standard three-view shoulder radiographs (AP in internal and external rotation plus axillary or scapula-Y view) performed upright, as this is the preferred initial diagnostic modality that can identify fractures, dislocations, and malalignment that require urgent orthopedic referral. 1, 2

Initial Imaging Approach

• Obtain radiographs first because they effectively demonstrate fractures, dislocations, and shoulder malalignment, and can be performed immediately in most clinical settings 1, 2
• The axillary or scapula-Y view is vital—acromioclavicular and glenohumeral joint dislocations are frequently misclassified on AP views alone 1, 3
• Perform radiography with the patient upright, as supine positioning can underrepresent shoulder malalignment 3

History and Physical Examination Priorities

Focus your clinical assessment on these specific elements that guide management:

• Mechanism of injury: Determine if trauma occurred (fall, direct blow, overhead activity) as this separates traumatic from atraumatic causes 1
• Pain with overhead activity and weakness: These findings combined with positive impingement signs suggest rotator cuff pathology 4
• Age considerations: Patients under 40 with instability history suggest glenohumeral instability; patients over 50 with gradual onset suggest osteoarthritis 4
• Range of motion assessment: Restricted passive range of motion with diffuse pain indicates adhesive capsulitis 4
• Specific provocative tests: Empty can test, external rotation strength testing, cross-body adduction (for AC joint), apprehension and relocation tests (for instability) 4, 5

Immediate Referral Criteria

Refer immediately to orthopedic surgery if radiographs show: 2

• Unstable or significantly displaced fractures
• Shoulder joint dislocation or instability
• Any neurological deficits on examination

Delaying surgical referral when indicated makes stabilization more technically challenging 2

Advanced Imaging (If Radiographs Are Normal)

If radiographs are noncontributory but symptoms persist at 2 weeks:

• MRI without contrast (rating 7/9) or MR arthrography (rating 9/9) for suspected soft tissue injuries including rotator cuff tears, labral tears, or capsular pathology 2
• Ultrasound can effectively evaluate rotator cuff tears, subdeltoid subacromial bursitis, biceps tendinosis, and guide therapeutic injections 6
• CT scan only if radiographs show bony abnormalities requiring better fracture characterization 2

Common Pitfalls to Avoid

• Missing orthogonal views: Failure to obtain axillary or scapula-Y views leads to missed dislocations 3, 2
• Supine radiographs: These underrepresent malalignment—always image upright 3
• Treating images instead of the patient: Imaging abnormalities may be asymptomatic and not the source of current pain 6
• Inadequate initial imaging: This leads to missed fracture components and underestimation of injury severity 2

Conservative Management Considerations

For soft tissue injuries without surgical indications (rotator cuff tendinopathy, bursitis, mild AC joint pathology):

• Pain control and therapeutic exercises form the foundation of treatment 7
• Ultrasound-guided steroid injections can be effective for bursitis, calcific tendinosis, and AC joint osteoarthritis 6
• Caveat: Massive traumatic rotator cuff tears may require expedited surgical repair for optimal functional outcomes, so don't delay advanced imaging if clinical suspicion is high 1