What is the recommended evaluation and initial management for a patient presenting with shoulder pain?

Evaluation and Initial Management of Shoulder Pain

Immediate First Step: Obtain Standard Three-View Radiographs

Standard radiography is mandatory as the initial imaging study for any patient presenting with shoulder pain, regardless of suspected etiology 1, 2, 3. This must include anteroposterior views in both internal and external rotation plus either an axillary or scapula-Y view, performed with the patient upright 1, 2, 3.

Critical Technical Requirements:

• Never rely on AP views alone—the axillary or scapula-Y view is essential because standard AP projections miss up to 50% of glenohumeral and acromioclavicular dislocations 1, 2
• Obtain radiographs upright, not supine—supine positioning significantly underrepresents shoulder malalignment and leads to missed pathology 1, 2
• Do not skip directly to MRI or ultrasound even when soft-tissue pathology seems obvious; radiographs exclude fractures and dislocations that alter management 2, 3

---

Essential History Components

Mechanism and Timing:

• Document whether pain is traumatic (directly attributed to a specific injury event) or atraumatic, as this fundamentally divides the diagnostic pathway 1, 2
• Classify timing as acute (≤2 weeks) versus chronic (≥6 months), which influences both differential diagnosis and management strategy 2
• For traumatic presentations, record exact mechanism including fall height, landing position, and how the injury occurred 2

Age-Specific Questioning Strategy:

• Patients under 35-40 years: Prioritize questions about shoulder instability, sensation of "giving way," history of dislocation/subluxation events, labral symptoms, and sports-related mechanisms 2
• Patients over 35-40 years: Focus on rotator cuff symptoms (pain with overhead activities, weakness), degenerative changes, impingement patterns, and arthritic symptoms 2

Pain Location and Character:

• Anterior shoulder pain suggests rotator cuff or biceps tendon pathology 2
• Superior shoulder pain indicates acromioclavicular joint disease 2
• Scapular region pain may represent referred pain from cervical spine or rotator cuff pathology 2
• Pain with arm behind back (internal rotation/extension) specifically implicates subscapularis tendon and posterior rotator cuff structures 2

Red Flags to Screen:

• Fever, chills, or constitutional symptoms suggesting septic arthritis 2
• Neurological symptoms (numbness, tingling, weakness, radiation down arm) indicating cervical radiculopathy or nerve compression 2
• Absent radial or ulnar pulses after trauma requiring immediate vascular imaging 2

---

Physical Examination Framework

Age-Specific Examination Priorities:

For patients <35-40 years:

• Perform comprehensive instability assessment including apprehension test and posterior stress tests, as instability is the predominant pathology in this age group 2
• Focus on labral pathology evaluation 2

For patients ≥35-40 years:

• Focus examination on rotator cuff disease, degenerative changes, and impingement syndrome, which are the most common disorders in this cohort 2
• Look for muscle atrophy and fatty infiltration of supraspinatus and infraspinatus on inspection 2

Key Provocative Tests:

• Hawkins test (92% sensitive for subacromial impingement) 2
• Neer test (88% sensitive for subacromial impingement) 2
• Empty can test for supraspinatus pathology 2
• External rotation strength testing for rotator cuff integrity 2
• Cross-body adduction test for acromioclavicular joint pathology 2

Neurovascular Assessment:

• Palpate radial and ulnar pulses—absence after high-energy trauma or dislocation requires immediate vascular imaging 2

---

Advanced Imaging: When and What to Order

If Radiographs Are Normal but Pain Persists:

For acute traumatic shoulder pain with normal radiographs:

• Proceed directly to non-contrast MRI as the next study, because acute trauma typically produces joint effusion that naturally delineates soft-tissue structures without requiring contrast injection 2
• MRI effectively detects rotator cuff tears, labral injuries, bone marrow contusion, capsular tears, and ligamentous injuries 2

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

• MR arthrography is the gold-standard modality, providing superior visualization of capsulolabral structures compared to non-contrast MRI 2
• MR arthrography outperforms non-contrast MRI for detecting SLAP tears, labroligamentous injuries, and partial rotator cuff tears 2

For patients ≥35 years with suspected rotator cuff pathology:

• Either non-contrast MRI or high-resolution ultrasound (when performed by experienced operators) provides similarly high sensitivity and specificity for full-thickness rotator cuff tears 2
• Ultrasound allows dynamic assessment during arm movement and is cost-effective 2
• Ultrasound cannot adequately assess labral pathology or shoulder instability—use MRI/MR arthrography for these concerns 2

For traumatic injuries with fracture on radiographs:

• CT is recommended to delineate fracture patterns for surgical planning 1, 2

---

Initial Management Algorithm

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

Diagnostic criteria:

• Pain intensifying with arm abduction beyond 90° (impingement arc) 2
• Positive Hawkins and/or Neer tests 2
• Preserved active strength (roughly 4/5) during abduction past 90° 2

First-line management:

1. Refer to physical therapy program as the initial intervention—evidence-based conservative care leads to full recovery in approximately 80% of patients within 3-6 months 2
2. Complete rest from aggravating activities (overhead movements, abduction, internal rotation) until pain-free 2
3. Rehabilitation protocol must incorporate eccentric strengthening exercises, which are specifically recommended to promote tendinopathy healing 2
4. Improve range of motion through stretching and mobilization, focusing especially on external rotation and abduction to prevent frozen shoulder 2
5. Progress to rotator cuff and scapular stabilizer strengthening once pain-free motion is achieved 2

Adjunctive measures:

• NSAIDs for acute pain management 2
• Ice, heat, and soft tissue massage 2
• Intra-articular corticosteroid injections (triamcinolone) for more severe cases have significant effects on pain 2

Critical pitfalls to avoid:

• Avoid overhead pulley exercises—they encourage uncontrolled abduction and can worsen rotator cuff pathology 2
• Do not refer to orthopedics before completing a 3-6 month trial of adequate conservative therapy—only about 9% ultimately require surgical referral 2

When to obtain MRI:

• MRI is NOT required at initial evaluation when clinical findings clearly establish the diagnosis 2
• Order MRI only if: (1) symptoms persist despite 3-6 months of adequate conservative therapy, (2) clinical suspicion for full-thickness rotator cuff tear (marked strength loss), or (3) imaging needed for surgical planning 2

For Adhesive Capsulitis (Frozen Shoulder):

Diagnostic criteria:

• Diffuse shoulder pain with progressive loss of passive range of motion, particularly external rotation and abduction 2
• Often associated with diabetes and thyroid disorders 2

Management:

• Aggressive stretching and mobilization focusing on external rotation and abduction 2
• Serial casting for contractures interfering with function 2
• Avoid overhead pulley exercises 2

For Traumatic Injuries:

Unstable or significantly displaced fractures:

• Require prompt orthopedic referral for acute surgical management 1, 2

Stable fractures and most soft-tissue injuries:

• Can undergo a period of conservative management before considering surgery 1
• Rotator cuff tears, labral tears can be managed conservatively initially 1

Return to Activity:

• Allow return to activities only after completing a functional, progressive, individualized program over 1-3 months without evidence of symptoms 2

---

Common Diagnostic Pitfalls

• Do not assume absence of trauma means absence of fracture—osteoporotic fractures in elderly patients can occur with minimal or unrecognized trauma 2
• Misinterpreting shoulder instability pain as impingement, cervical disc disease, or AC joint pathology leads to incorrect management; differentiate these entities carefully 2
• Inadequate radiographic views leading to missed fracture components or dislocations is a common error 1, 2, 3
• Lateral rotation is the factor most significantly related to onset of shoulder pain, making external rotation exercises particularly important 2