Imaging and Early Management of Acute Post‑Traumatic Shoulder and Elbow Soft‑Tissue Injuries

Clinical Presentation Suggestive of Soft‑Tissue Injury

Severe limitation in shoulder abduction (< 45°), flexion (≈ 90°), and rotation (≈ 45°) after a fall on an outstretched arm strongly suggests rotator‑cuff or capsular injury. 2
Rotator‑cuff tear (partial or full‑thickness) is the diagnosis most consistent with the mechanism of injury, pain pattern, and marked functional limitation. 2
Acute shoulder capsular injury or adhesive capsulitis can develop rapidly after trauma and explains the global range‑of‑motion restriction. 2
Posterior‑lateral rib pain radiating to the posterior shoulder, aggravated by thoracic pressure and deep breathing, points to rib contusion or costochondral injury; a normal chest X‑ray makes fracture unlikely. 3
Rib contusion or costochondral injury may account for rib pain but is unlikely to produce the degree of shoulder dysfunction observed. 3

MRI of the left shoulder without IV contrast is recommended as the next imaging study in acute shoulder trauma with normal radiographs. (American College of Radiology) 2
MRI is the gold‑standard modality for evaluating rotator‑cuff tears, capsular injuries, and labral pathology in this setting. (American College of Radiology) 2
In acute shoulder trauma, post‑traumatic joint effusion or hemarthrosis provides sufficient soft‑tissue visualization on MRI, eliminating the need for IV contrast or arthrography. (American College of Radiology) 2
MRI also detects bone‑marrow edema indicating occult fractures that are not visible on plain films. (American College of Radiology) 2
If MRI is unavailable or contraindicated, shoulder ultrasound may be performed, but it has lower sensitivity for partial‑thickness rotator‑cuff tears and cannot comprehensively assess intra‑articular structures. (American College of Radiology) 2

The American College of Radiology advises against aggressive range‑of‑motion testing or physical therapy before imaging excludes significant rotator‑cuff or ligamentous injury, as premature mobilization may worsen outcomes. 2
Initiating physical therapy before MRI can convert a partial rotator‑cuff tear into a complete tear; therefore, therapy should be deferred until imaging is completed. 2

Full‑thickness rotator‑cuff tears in young, active patients usually require surgical repair to restore function and prevent chronic disability. (American College of Radiology) 2
Partial‑thickness rotator‑cuff tears may be managed conservatively with physical therapy and NSAIDs; surgical repair is indicated if symptoms persist after 3–6 months. (American College of Radiology) 2
Capsular tears and labral injuries often necessitate arthroscopic repair to restore joint stability and prevent recurrent instability. (American College of Radiology) 2