What is the appropriate evaluation and treatment for shoulder pain?

Evaluation and Treatment of Shoulder Pain

Initial Evaluation: Start with Plain Radiographs

Begin with plain radiographs (minimum 3 views: AP, Grashey, and axillary or scapular Y) for all patients presenting with shoulder pain, regardless of mechanism or suspected cause. 1

Red Flags Requiring Urgent Evaluation

• Fever with joint effusion suggesting septic arthritis—proceed immediately to ultrasound or x-ray-guided arthrocentesis 2, 1
• Acute neurologic deficits indicating possible nerve injury or compression 1
• Suspected cardiac or pulmonary pathology causing referred pain (lung neoplasms, pleural infections, or subdiaphragmatic disease can refer pain through the phrenic nerve) 1, 3
• Acute trauma with suspected fracture or dislocation requiring immediate orthopedic consultation 1

Physical Examination Priorities

Assess the following systematically 2, 1:

• Tone and strength of shoulder girdle muscles
• Soft tissue length changes and flexibility
• Joint alignment of the shoulder girdle
• Range of motion in all planes (particularly external rotation and abduction)
• Pain levels with specific movements
• Sensorimotor examination of the entire upper extremity to identify neuropathic features 1, 4

Age-Specific Considerations

• Patients under 35 years: Suspect labral tears and glenohumeral instability—look for recurrent subluxation, "dead arm" sensation, or mechanical symptoms 1
• Patients over 35 years: Rotator cuff disease becomes the predominant cause of instability-related symptoms 2

---

Advanced Imaging Algorithm (After Initial Radiographs)

If Fracture Identified

• CT without contrast to characterize fracture complexity, displacement, and aid surgical planning 1

If Suspected Instability or Dislocation

• MRI without IV contrast is the primary study 1
• CT without contrast may be considered when bone loss assessment is critical for surgical planning 1

If Suspected Labral Tears

• MR arthrography is the reference standard in subacute or chronic settings 1
• MRI without contrast is preferred in acute trauma 1
• MRA is generally recommended for patients aged <35 years due to higher prevalence of instability-related labral pathology 2

If Suspected Rotator Cuff Tears

• MRI without contrast or ultrasound are equivalent first-line studies 1
• Choice depends on local expertise and availability 2, 1
• Ultrasound can evaluate the acromioclavicular joint, rotator cuff tendons, and long head of biceps tendon, but is operator-dependent and limited for deep structures 2

If Suspected Septic Arthritis (Radiographs Noncontributory)

• Ultrasound or x-ray-guided arthrocentesis (both rated 9/9—equally appropriate) 2
• Aspiration is the procedure of choice; imaging is adjunctive 2

---

Treatment Algorithm Based on Diagnosis

Pharmacologic Management

NSAIDs such as ibuprofen 400-800 mg three to four times daily for initial pain management 1

Acetaminophen for pain relief when no contraindications exist 1

Neuromodulating medications (gabapentin or pregabalin) when neuropathic features are present, including 1, 4:

• Electric shock sensations
• Sensory changes
• Allodynia or hyperpathia
• Pain with specific movements suggesting nerve irritation

Physical Therapy Approach

Gentle stretching and mobilization techniques focusing on 2, 1:

• Increasing external rotation and abduction gradually
• Active range of motion increased in conjunction with restoring alignment
• Strengthening weak muscles in the shoulder girdle
• Scapular stabilization exercises 4

Specific Interventions for Hemiplegic Shoulder Pain (Post-Stroke)

• Subacromial corticosteroid injections when pain is related to injury or inflammation of the rotator cuff or bursa 2
• Botulinum toxin injections into subscapularis and pectoralis muscles when pain is related to spasticity 2

Activity Modification

Avoid repetitive overhead movements that trigger symptoms during the acute phase 4

---

Critical Pitfalls to Avoid

Never dismiss neuropathic symptoms (electric shock sensations, burning, allodynia) as "normal postoperative pain"—these require specific evaluation for nerve pathology and targeted treatment with neuromodulating agents, not just NSAIDs 1, 4

Do not skip initial radiographs—they are essential for all presentations before proceeding to advanced imaging 1

Do not order MR arthrography in the acute postoperative setting—standard MRI without contrast is sufficient and appropriate 1, 4

Do not delay urgent referral for red flag diagnoses including septic arthritis, acute neurologic deficits, or fractures requiring fixation 1

Consider referred pain sources when musculoskeletal examination is unrevealing—cervical spine pathology, thoracic outlet syndrome, and intrathoracic/subdiaphragmatic pathology can all present as shoulder pain 3, 5