What is the recommended approach to assess and initially manage a patient with right shoulder pain?

Assessment and Initial Management of Right Shoulder Pain

Begin with standard three-view radiography (AP in internal and external rotation plus axillary or scapula-Y view, performed upright) as your initial imaging study, then proceed with a focused history and physical examination to determine whether the pain is traumatic or atraumatic and to guide further management. 1, 2

Initial Imaging Protocol

Radiography is the mandatory first imaging study for all shoulder pain presentations. 1, 2

• Obtain at minimum three views: anteroposterior projections in internal and external rotation, plus either an axillary or scapula-Y view 1, 2
• The axillary or scapula-Y view is non-negotiable because AP views alone miss up to 50% of glenohumeral and acromioclavicular dislocations 1
• Perform imaging with the patient upright rather than supine, as supine positioning underrepresents shoulder malalignment 1, 2
• For suspected instability or dislocation, a Grashey projection (30° posterior oblique) should be added to profile the glenohumeral joint 1

Critical Pitfall

Never skip radiographs and proceed directly to MRI or ultrasound, even when soft-tissue pathology seems obvious—bony pathology must be excluded first. 2

History Taking: Key Elements

Mechanism and Timing

• Document whether pain is traumatic (directly attributed to a specific event with known mechanism, fall height, landing position) or atraumatic 1, 3
• Classify timing as acute (<2 weeks) versus chronic (>6 months), as this fundamentally changes your differential diagnosis 1, 3
• Record any history of previous shoulder dislocations, fractures, or repairs 3

Pain Location and Character

• Anterior shoulder pain suggests rotator cuff or biceps tendon pathology 3
• Superior shoulder pain indicates acromioclavicular joint disease 3
• Scapular region pain may represent referred pain from cervical spine or rotator cuff 3
• Pain with internal rotation and arm-behind-back movements specifically implicates the subscapularis tendon 3

Age-Specific Focus

• Patients <35-40 years: Prioritize questions about instability (shoulder "giving way"), labral tears, and sports-related injuries 1, 3
• Patients ≥35-40 years: Focus on rotator cuff disease, degenerative changes, impingement syndrome, and arthritis 1, 3

Red Flags

• Screen for neurological symptoms (numbness, tingling, weakness, radiation down arm) suggesting cervical radiculopathy 3
• Ask about systemic symptoms (fever, chills, constitutional symptoms) indicating possible septic arthritis 3
• In elderly patients, remember that osteoporotic fractures can occur with minimal or unrecognized trauma 3

Physical Examination: Structured Approach

Inspection and Palpation

• Look for muscle atrophy (particularly supraspinatus and infraspinatus in chronic rotator cuff tears) 3
• Palpate radial and ulnar arterial pulses—absence of pulse after trauma or dislocation requires immediate vascular imaging 3

Range of Motion Testing

• Assess both active and passive range of motion in all planes 4
• Limited passive motion (especially external rotation and abduction) suggests adhesive capsulitis 3
• Preserved passive motion with painful/weak active motion indicates rotator cuff pathology 3

Age-Specific Examination Strategy

For patients <40 years:

• Perform comprehensive instability assessment with apprehension and posterior stress tests 3
• Focus on labral pathology evaluation 3

For patients ≥35-40 years:

• Perform Hawkins test (92% sensitive) and Neer test (88% sensitive) for impingement syndrome 3
• Test for rotator cuff tears with empty can test and external rotation weakness 3
• Pain intensifying when arm is abducted beyond 90° indicates subacromial impingement 3

Neurovascular Assessment

• Complete sensorimotor examination of the upper extremity 4
• Evaluate cervical spine and elbow to exclude referred pain 5, 4
• Screen for complex regional pain syndrome in chronic post-traumatic cases without clear etiology 3

Advanced Imaging: When and What to Order

After Non-Contributory Radiographs

For patients ≥35 years with suspected rotator cuff pathology:

• MRI without contrast is the preferred study for rotator cuff disorders, tendinopathy, or tears 3
• Ultrasound (if local expertise available) is equivalent to MRI for rotator cuff and biceps tendon evaluation with 85% sensitivity and 90% specificity 3

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

• MR arthrography is the gold standard, providing superior visualization of capsulolabral structures 1, 3
• MR arthrography is superior to non-contrast MRI for diagnosing SLAP tears, labroligamentous injuries, and partial rotator cuff tears 1

For traumatic injuries:

• CT is indicated when radiographs show fracture and you need to characterize the fracture pattern for surgical planning 1
• MR arthrography remains the gold standard for traumatic shoulder pain when soft-tissue injury is suspected 1

Important Caveat

Do not order MRI at initial evaluation when clinical findings (positive impingement signs, characteristic pain pattern, appropriate age) clearly establish the diagnosis of subacromial impingement—MRI is only appropriate if symptoms persist despite 3-6 months of conservative therapy or if a full-thickness tear is suspected. 3

Initial Management Based on Diagnosis

For Subacromial Impingement Syndrome (Most Common in ≥35 Years)

Refer to physical therapy as first-line treatment—80% of patients achieve full recovery within 3-6 months with conservative care. 3

• Complete rest from aggravating activities until asymptomatic 3
• Improve range of motion through stretching and mobilization, focusing on external rotation and abduction 3
• Begin rotator cuff and scapular stabilizer strengthening once pain-free motion is achieved 3
• Avoid overhead pulley exercises, which encourage uncontrolled abduction and worsen rotator cuff pathology 3
• Consider NSAIDs for acute pain management 3
• Intra-articular corticosteroid injections (triamcinolone) for more severe cases 3
• Orthopedic referral is premature before a 3-6 month trial of conservative therapy; only 9% ultimately require surgery 3

For Adhesive Capsulitis

• Aggressive stretching and mobilization focusing on external rotation and abduction 3
• Serial casting for contractures interfering with function 3
• Avoid overhead pulley exercises 3

For Traumatic Injuries

• Unstable or significantly displaced fractures require acute orthopedic referral 1
• Stable injuries can undergo conservative management before considering surgery 1

Return to Activity

Allow return to activities only after completing a functional, progressive, individualized program over 1-3 months without symptoms. 3