What is the proper method to assess and document shoulder and hip pain in a patient?

Assessment and Documentation of Shoulder and Hip Pain

Begin with plain radiographs as the mandatory first imaging study for both shoulder and hip pain, followed by a structured clinical examination that prioritizes age-specific pathology and mechanism of injury. 1

Initial Clinical History Documentation

Shoulder Pain History

Document the precise mechanism of injury including fall height, landing position, and whether trauma occurred, as this directly impacts differential diagnosis and imaging selection. 2

• Record symptom duration to classify as acute (<2 weeks) versus chronic (>6 months), which fundamentally changes the diagnostic approach and imaging pathway. 1, 2
• Distinguish traumatic (attributed to specific event) from atraumatic presentations, as this determines whether instability workup is needed. 1, 2
• Document prior shoulder injuries including dislocations, fractures, or repairs, since recurrent instability has different imaging requirements. 2

Pain location provides anatomic clues: anterior shoulder suggests rotator cuff or biceps pathology; superior shoulder indicates acromioclavicular joint disease; scapular region may indicate referred cervical spine pain. 2

• For patients >35-40 years, focus history on rotator cuff disease, degenerative changes, and impingement symptoms (pain with overhead activities, weakness with abduction). 1, 2
• For patients <35-40 years, prioritize questions about instability, labral tears, and sports injuries, as these are the predominant pathologies in younger patients. 1, 2

Screen for red flags: fever, chills, or constitutional symptoms suggesting septic arthritis; neurological symptoms (numbness, tingling, weakness) indicating cervical radiculopathy or nerve compression. 1, 2

Hip Pain History

Document pain characteristics, duration, and functional limitations systematically, as hip pain has multiple extra-articular and intra-articular sources. 1

• Assess for referred pain from lumbar spine, sacroiliac joints, or knee, which commonly masquerades as hip pathology. 1
• Record specific aggravating activities (walking, stair climbing, prolonged sitting) to differentiate intra-articular from extra-articular pathology. 1

Physical Examination Components

Shoulder Examination

Perform inspection, palpation, range of motion assessment, and provocative testing in all patients. 3, 4, 5

Age-specific examination priorities:

• In patients <40 years, perform comprehensive instability assessment including apprehension and posterior stress tests, as instability is the predominant pathology. 2
• In patients ≥35-40 years, focus on rotator cuff disease, impingement signs, and degenerative changes, which are the most common disorders. 2

Key provocative tests:

• Hawkins test (92% sensitive) and Neer test (88% sensitive) for subacromial impingement. 2
• Empty can test and external rotation weakness testing for rotator cuff pathology. 2
• Assess passive range of motion: limited passive motion suggests adhesive capsulitis, while preserved passive with painful/weak active motion indicates rotator cuff pathology. 2

Neurovascular assessment: Palpate radial and ulnar pulses; absence requires immediate vascular imaging after high-energy trauma or dislocation. 2

Hip Examination

Perform systematic inspection, palpation, range of motion, and gait assessment. 1

• Evaluate lumbar spine, sacroiliac joints, and knee to exclude referred pain sources. 1
• Assess for trochanteric tenderness suggesting trochanteric bursitis or abductor tendinopathy. 1

Imaging Algorithm

Shoulder Imaging

Radiography is the mandatory initial screening modality for all shoulder pain presentations. 1

Standard shoulder trauma series requires ≥3 views with 2 orthogonal projections:

• Grashey projection (AP to scapula with 30° posterior oblique) to profile the glenohumeral joint. 1
• Axillary lateral view or scapular Y view for instability or dislocation assessment. 1
• Frontal views (AP with humerus neutral, internal, or external rotation). 1

After radiographs, imaging selection depends on age and clinical findings:

For patients ≥35 years with suspected rotator cuff pathology:

• MRI shoulder without contrast is the procedure of choice (rating 9/9). 1
• Ultrasound is equivalent to MRI for rotator cuff evaluation when performed by experienced operators (sensitivity 85%, specificity 90%). 1, 2

For patients <35 years with suspected labral tear or instability:

• MR arthrography is the preferred modality (rating 9/9) for superior visualization of capsulolabral structures. 1, 2
• MRI without contrast is acceptable with optimized equipment (rating 7/9). 1

For fracture characterization when radiographs show fracture:

• CT without contrast is most appropriate for delineating fracture planes, displacement, and angulation. 1

For suspected septic arthritis:

• Ultrasound-guided or fluoroscopy-guided arthrocentesis (both rating 9/9) for aspiration and culture. 1

Hip Imaging

Radiographs of pelvis and hip are the mandatory first test for chronic hip pain. 1

• Include pelvis view plus proximal femur view, which is superior to ipsilateral hip alone for detecting dysplasia, referred pain sources, and comparison. 1

After negative, equivocal, or nondiagnostic radiographs:

For suspected extra-articular soft tissue abnormality (trochanteric bursitis, abductor tendinopathy, iliopsoas bursitis):

• MRI hip without IV contrast (rating 9/9) or ultrasound (rating 9/9) are both appropriate. 1

For suspected labral tear:

• MR arthrography (rating 9/9), CT arthrography (rating 9/9), or MRI without contrast (rating 8/9) are all appropriate. 1

For suspected femoroacetabular impingement:

• MR arthrography (rating 9/9) or CT arthrography (rating 9/9) are most appropriate. 1

For suspected infection with positive radiographs:

• MRI hip with or without IV contrast (rating 9/9) or image-guided aspiration (rating 9/9). 1

Documentation Requirements

Record all examination findings systematically:

• Inspection findings (atrophy, asymmetry, swelling, ecchymosis)
• Palpation findings (point tenderness, crepitus)
• Active and passive range of motion with degrees measured
• Strength testing results (graded 0-5/5)
• Results of all provocative tests performed
• Neurovascular status

Document imaging ordered with clinical indication:

• Specify suspected diagnosis guiding imaging selection
• Note age of patient (critical for shoulder imaging pathway)
• Record mechanism if traumatic
• Document prior imaging and results

Common pitfall: Do not assume absence of trauma means absence of fracture, especially in elderly patients where osteoporotic fractures occur with minimal or unrecognized trauma. 2

Critical error to avoid: Ordering MRI before radiographs violates evidence-based imaging algorithms and may miss fractures or other bony pathology best seen on plain films. 1