Initial Evaluation and Management of Shoulder Pain

Clinical Assessment

• A thorough clinical history should focus on mechanism of injury, as traumatic shoulder pain can be directly attributed to acute or chronic traumatic events 3, 2
• Determine if the pain is traumatic (fractures, dislocations) or non-traumatic (rotator cuff disorders, inflammatory conditions) in nature 1
• Assess for red flags that may require urgent referral, including significant trauma, joint instability, or neurological symptoms 2

Initial Imaging

• Standard radiographic evaluation should include at minimum three views: anteroposterior (AP) views in internal and external rotation, axillary or scapula-Y view, and the Stryker notch view can be used to evaluate Hill-Sachs lesions 3, 1, 4, 2
• Radiographs should be performed upright, as shoulder malalignment can be underrepresented on supine radiography 3, 4

Management Approach

• Separate injuries into two categories: those requiring acute surgical management (unstable/displaced fractures, joint instability) and those appropriate for initial conservative management (most soft-tissue injuries) 1, 2
• Refer patients with unstable or significantly displaced fractures and joint instability for surgical evaluation 1
• Traumatic massive rotator cuff tears may require expedited surgical referral for optimal functional outcomes 1

Special Considerations

• Patient factors such as age, comorbidities, and expected activity level help determine appropriate management strategy 1
• Failure to obtain axillary or scapula-Y views can lead to missed diagnoses of acromioclavicular and glenohumeral dislocations 3, 2
• Delaying treatment of traumatic massive rotator cuff tears may lead to suboptimal functional outcomes 1