What is the most appropriate first step in managing a patient with anterior shoulder pain and soreness?

Initial Management of Anterior Shoulder Pain and Soreness

Begin with a focused clinical history documenting mechanism of injury (traumatic vs. atraumatic), pain location, aggravating activities, and age-specific risk factors, followed immediately by plain radiographs (minimum 3 views: AP internal/external rotation plus axillary or scapular-Y view) to exclude fracture and dislocation before proceeding to conservative management. 1, 2

Step 1: Obtain Critical History Elements

Document these specific details first:

• Mechanism: Was there a specific traumatic event (fall, direct blow, sudden pull) or gradual onset from repetitive activities? 1, 2
• Pain location: Anterior shoulder pain specifically suggests rotator cuff pathology (particularly subscapularis), biceps tendinopathy, or labral injury 1
• Aggravating factors: Pain with overhead activities, reaching behind back (internal rotation), or cross-body adduction helps narrow the differential 1
• Age: This is critical—patients under 35-40 years have instability and labral tears as primary pathology, while those over 35-40 years predominantly have rotator cuff disease and degenerative changes 1, 3
• Instability symptoms: Any history of shoulder "giving way," subluxation, or dislocation events 1
• Red flags: Fever, constitutional symptoms (septic arthritis), or neurological symptoms (cervical radiculopathy) 1

Step 2: Perform Targeted Physical Examination

Execute these specific maneuvers:

• Painful arc test (most accurate for rotator cuff disease; positive LR 3.7): Pain between 70-120° of abduction 4, 1
• External rotation lag test (most accurate for full-thickness tears; positive LR 7.2): Patient cannot maintain arm in externally rotated position 4
• Internal rotation lag test (positive LR 5.6 for full-thickness tears): Inability to maintain hand behind back 4
• Hawkins test (92% sensitive for impingement): Forward flex to 90°, then forcibly internally rotate 1, 3
• Neer test (88% sensitive for impingement): Forced forward elevation with scapula stabilized 1, 3
• Assess passive range of motion: Preserved passive motion with painful/weak active motion = rotator cuff pathology; restricted passive motion = adhesive capsulitis 1

Step 3: Obtain Plain Radiographs Immediately

Order these specific views before any other imaging or treatment:

• Minimum 3-view series: AP with internal rotation, AP with external rotation, and axillary lateral OR scapular-Y view 5, 2
• Critical caveat: Never rely on AP views alone—glenohumeral and acromioclavicular dislocations are frequently missed without the orthogonal view 5, 2
• Perform upright, not supine: Shoulder malalignment is significantly underrepresented on supine films 5, 2
• Purpose: Exclude fracture (clavicle, scapula, proximal humerus) and dislocation before initiating conservative management 5, 2

Step 4: Initiate Conservative Management (If Radiographs Normal)

For patients over 35-40 years with clinical rotator cuff pathology:

• Complete rest from all aggravating activities until asymptomatic 1
• NSAIDs for acute pain control 1
• Physical therapy referral focusing on:
  • Range of motion restoration through stretching (especially external rotation and abduction) 1
  • Progressive rotator cuff and scapular stabilizer strengthening once pain-free motion achieved 1
  • Eccentric strengthening exercises specifically for tendinopathy healing 1
• Avoid overhead pulley exercises: These encourage uncontrolled abduction and worsen rotator cuff pathology 1
• Expected timeline: 80% of patients with subacromial impingement recover fully within 3-6 months of supervised physical therapy 1

For patients under 35 years with suspected instability:

• Physical therapy focusing on dynamic stabilization and proprioceptive training 1
• Consider MR arthrography if instability symptoms persist or surgical planning needed 5, 1

Step 5: Advanced Imaging (Only If Indicated)

MRI without contrast is appropriate when:

• Clinical diagnosis remains unclear after history, examination, and radiographs 5, 1
• Symptoms persist despite 3-6 months of adequate conservative therapy 1
• Clinical suspicion for full-thickness rotator cuff tear (marked weakness, positive lag signs) 1, 4
• Patient age >35 years with suspected rotator cuff pathology requiring surgical planning 5, 1

Musculoskeletal ultrasound is equivalent to MRI when:

• Experienced operators available (85% sensitivity, 90% specificity for rotator cuff pathology) 1
• Dynamic assessment during arm movement needed 1
• Cost-effective alternative preferred 1

MR arthrography is preferred for:

• Patients <35 years with suspected labral tears or instability 5, 1
• Evaluation of capsulolabral structures when surgical planning required 5, 1

Critical Pitfalls to Avoid

• Do not skip radiographs: Even atraumatic presentations can have fractures, especially in elderly patients with osteoporosis 1
• Do not order MRI as first-line imaging: Radiographs must come first to exclude fracture and dislocation 5, 2
• Do not misinterpret instability pain: Young patients with instability are often misdiagnosed with impingement, leading to incorrect treatment 1
• Do not refer to orthopedics prematurely: 80% of impingement cases resolve with 3-6 months of conservative therapy; only 9% ultimately require surgery 1
• Do not obtain only AP views: This misses dislocations and AC joint pathology 5, 2