What is the most appropriate initial step in evaluating and managing a patient presenting with right shoulder pain?

Initial Evaluation and Management of Right Shoulder Pain

Begin with plain radiographs (anteroposterior in internal and external rotation plus axillary or scapular Y view) as the mandatory first imaging study, then proceed with a focused history emphasizing mechanism of injury, age-specific pathology, and targeted physical examination maneuvers to guide further management. 1

Immediate Imaging Protocol

• Obtain three-view plain radiographs upright (AP internal rotation, AP external rotation, and axillary or scapular Y view) as the first diagnostic step for any shoulder pain presentation 1
• The axillary or scapular Y view is non-negotiable because standard AP views alone miss up to 50% of glenohumeral and acromioclavicular dislocations 1
• Add a Grashey (30° posterior oblique) projection when instability or dislocation is suspected to better profile the glenohumeral joint 1
• Upright positioning is essential; supine films underrepresent malalignment and lead to missed pathology 1

Critical History Elements

Mechanism and Timing

• Document whether pain is traumatic (linked to specific injury event) versus atraumatic, as this fundamentally alters your differential diagnosis 1
• Classify timing as acute (≤2 weeks) or chronic (≥6 months) to guide work-up intensity 1
• For traumatic presentations, record exact mechanism including fall height, landing position, and work-relatedness 1

Age-Specific Questioning Strategy

For patients <35-40 years:

• Prioritize questions about shoulder instability episodes, sensation of "giving way," history of dislocations or subluxations 1
• Ask about sports-related mechanisms and labral injury symptoms 1
• Focus physical examination on comprehensive instability assessment including apprehension and posterior stress tests 1

For patients ≥35-40 years:

• Focus on rotator cuff disease symptoms: pain with overhead activities, weakness during pushup movements, night pain 1
• Ask about degenerative changes, impingement symptoms, and arthritic complaints 1
• Examine for rotator cuff pathology, muscle atrophy, and impingement signs 1

Pain Location Mapping

• Anterior shoulder pain suggests rotator cuff or biceps tendon pathology 1
• Superior shoulder pain indicates acromioclavicular joint disease 1
• Scapular region pain may represent referred pain from cervical spine or rotator cuff 1
• Pain with internal rotation and arm-behind-back movements specifically implicates subscapularis tendon and posterior rotator cuff structures 1

Physical Examination Algorithm

Inspection and Palpation

• Assess for loss of symmetry, muscle atrophy (particularly supraspinatus and infraspinatus in older patients), and visible deformity 1, 2
• Palpate radial and ulnar arterial pulses; absence of pulse after trauma or dislocation requires immediate vascular imaging (duplex ultrasound or CT angiography) 1

Range of Motion Testing

• Distinguish between passive and active range of motion 1
• Limited painful passive abduction suggests adhesive capsulitis 1
• Preserved passive motion with painful/weak active abduction indicates rotator cuff pathology 1
• Pain intensifying when arm is abducted beyond 90° is the hallmark impingement arc, reflecting supraspinatus compression under the coracoacromial arch 1

Provocative Testing for Impingement

• Hawkins test (92% sensitive for subacromial impingement): forward flex shoulder to 90°, then forcibly internally rotate 1
• Neer test (88% sensitive): passively forward flex arm while stabilizing scapula 1
• Positive tests with preserved active strength of approximately 4/5 during abduction past 90° suggests chronic degenerative tendinopathy without complete tear 1

Rotator Cuff Specific Tests

• Empty can test for supraspinatus: abduct arms to 90° in scapular plane, internally rotate thumbs down, resist downward pressure 1
• Test external rotation strength to assess infraspinatus and teres minor 1
• Focal weakness with decreased range of motion during abduction with external or internal rotation indicates rotator cuff pathology 1

Instability Testing (Patients <40 Years)

• Perform apprehension test and posterior stress tests as comprehensive instability assessment 1
• Document any history of shoulder "giving way" or feeling unstable during activities 1

Red Flag Screening

• Screen for systemic symptoms (fever, chills, constitutional symptoms) indicating possible septic arthritis 1
• Evaluate for neurological symptoms (numbness, tingling, weakness, radiation down arm) suggesting cervical radiculopathy or nerve compression 1
• In chronic post-traumatic shoulder pain lacking clear etiology, evaluate for complex regional pain syndrome; early identification prompts multidisciplinary referral 1
• Do not assume absence of trauma means absence of fracture in elderly patients, where osteoporotic fractures occur with minimal or unrecognized trauma 1

Advanced Imaging Decision Algorithm

When Radiographs Are Normal

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

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

For patients ≥35 years with suspected rotator cuff disease:

• MRI without contrast is the preferred imaging modality 3, 1
• Ultrasound is equivalent to MRI when performed by experienced operators and is cost-effective 3, 1
• Ultrasound allows dynamic assessment during arm movement and visualizes tendon tears, tendinopathy, and bursal fluid with 85% sensitivity and 90% specificity 1

When fracture is evident on radiographs:

• CT is recommended to delineate fracture patterns for surgical planning 1
• For traumatic shoulder pain where soft-tissue injury is suspected alongside fracture, MR arthrography remains preferred 1

Postoperative Shoulder Pain

• MRI without IV contrast is the primary study when radiographs are noncontributory, assessing nerve structures, rotator cuff integrity, labral pathology, and soft tissue inflammation 4
• Consider ultrasound if significant metallic artifact from hardware would limit MRI quality 4

Initial Management Based on Diagnosis

Subacromial Impingement Syndrome (Most Common in ≥35 Years)

This is the appropriate pathway when clinical findings clearly establish impingement:

• Refer to physical therapy program as first-line intervention; evidence-based conservative care leads to full recovery in approximately 80% of patients within 3-6 months 1
• MRI is not required at initial evaluation when clinical findings (positive Hawkins/Neer tests, characteristic pain pattern, appropriate age) clearly establish diagnosis 1
• MRI becomes appropriate only if symptoms persist despite 3-6 months of adequate conservative therapy, there is clinical suspicion for full-thickness tear (marked strength loss), or imaging is needed for surgical planning 1

Conservative treatment protocol:

• Complete rest from aggravating activities (overhead movements, abduction, internal rotation) until pain-free 1
• Improve range of motion through stretching and mobilization, focusing especially on external rotation and abduction to prevent frozen shoulder 1
• Eccentric strengthening exercises are specifically recommended to promote tendinopathy healing 1
• Rotator cuff and scapular stabilizer strengthening once pain-free motion is achieved 1
• Avoid overhead pulley exercises, which encourage uncontrolled abduction and worsen rotator cuff pathology 1

Adjunctive treatments:

• NSAIDs for acute pain management 1
• Intra-articular corticosteroid injections (triamcinolone) for more severe cases 1
• Consider functional electrical stimulation to improve shoulder lateral rotation 1
• Consider shoulder strapping as preventive and therapeutic intervention 1

Referral timing:

• Orthopedic referral is premature before a well-managed 3-6 month trial of conservative therapy 1
• Only approximately 9% of individuals with subacromial impingement ultimately require surgical referral after unsuccessful conservative management 1

Adhesive Capsulitis

• Aggressive stretching and mobilization focusing on external rotation and abduction 1
• Serial casting for contractures interfering with function 1
• Avoid overhead pulley exercises 1

Suspected Septic Arthritis

• Ultrasound-guided or fluoroscopy-guided arthrocentesis is the procedure of choice (both rated 9/9 appropriateness) 3
• Aspiration takes priority over imaging; MRI without and with contrast may be appropriate if clinical concern warrants after aspiration 3

Fracture Management

• Unstable or significantly displaced fractures require prompt orthopedic referral for definitive care 1
• Stable fracture patterns may be managed conservatively initially, with orthopedic consultation deferred until failure of non-operative measures 1

Common Pitfalls to Avoid

• Misinterpreting shoulder instability pain as impingement, cervical disc disease, or AC joint pathology leads to incorrect management; differentiate these entities carefully 1
• Do not dismiss neuropathic symptoms (electric shock sensations) as "normal postoperative pain"; evaluate specifically for nerve pathology and treat with neuromodulating agents (gabapentin or pregabalin) rather than just NSAIDs 4
• Do not order MR arthrography in the acute postoperative setting; standard MRI without contrast is sufficient 4
• Lateral rotation is the factor most significantly related to onset of shoulder pain, making external rotation exercises particularly important 1