Initial Management of Shoulder Pathologies

Evaluation and Diagnosis

The American College of Radiology recommends that standard radiographic evaluation should include at least three views: anteroposterior in internal and external rotation, and an axillary or scapula-Y view to properly assess shoulder alignment 1
Radiographs should be performed in a standing position because poor shoulder alignment may be underestimated in a supine position 1, 2
It is essential to distinguish between traumatic injuries (fractures, dislocations) and non-traumatic pathologies (rotator cuff disorders, inflammatory conditions) 2

The American Academy of Orthopaedic Surgeons suggests that injections of corticosteroids may be considered for subacromial conflict, although evidence is insufficient to formally recommend their use in glenohumeral arthritis 3
For biceps tendinopathy, viscosupplementation with hyaluronic acid injections may be a therapeutic option 3
The American Academy of Orthopaedic Surgeons recommends that patients with shoulder instability or dislocations should be referred for surgical evaluation 2
Rehabilitation should focus on strengthening the rotator cuff, periscapular muscles, and core musculature 4

For hemiplegic shoulder post-stroke, patient and family education on range of motion and positioning is recommended for pain management 5
Injections of botulinum toxin may be useful for reducing severe hypertonia of the hemiplegic shoulder muscles 5
Suprascapular nerve blocks may be effective in reducing hemiplegic shoulder pain up to 12 weeks after treatment 5

Surgery should be considered for unstable or significantly displaced fractures and joint instability 1, 2
For glenohumeral arthritis, total shoulder arthroplasty is suggested rather than hemiarthroplasty 6
Massive traumatic tears of the rotator cuff may require prompt surgical referral for optimal functional outcomes 2

The American College of Radiology notes that ultrasonography is comparable to MRI for evaluating complete rotator cuff tears but is inferior for evaluating partial tears 1

The American College of Radiology recommends MRI without contrast for patients who have failed conservative management after 6-12 weeks of appropriate physical therapy, or for those with clinical features suggesting a full-thickness tear, such as significant weakness on resisted external rotation, positive impingement signs, or age >60 years with a combination of these findings 7, 8
MRI is also indicated for surgical planning if operative repair is being considered, and can help guide treatment by identifying full-thickness tears, tendon retraction, muscle atrophy, and fatty infiltration 7, 8

Full-thickness tears on MRI show increased signal intensity extending from inferior to superior tendon surface on all sequences, and can inform the decision between conservative and operative repair 8
Tendon retraction, muscle atrophy, and fatty infiltration on MRI can help determine the appropriateness of conservative vs. operative repair and predict postoperative prognosis 7, 8
Partial-thickness tears may require MR arthrography (MRA) if distinction from full-thickness tear is unclear, as recommended by the American College of Radiology 7, 8

The American College of Radiology suggests referring patients for orthopedic surgical evaluation if they have a full-thickness tear with tendon retraction, muscle atrophy, or fatty infiltration on MRI, indicating a potential need for operative repair 7, 8

The American College of Radiology recommends obtaining standard shoulder radiographs (anteroposterior views in internal and external rotation plus an axillary or scapula‑Y view) immediately as the first imaging step in patients with a positive Empty‑can and Drop‑arm test. 9
The American College of Radiology states that the primary purpose of these radiographs is to rule out fracture, dislocation, significant arthritis, or calcific tendinitis before proceeding to advanced imaging. 10

The American College of Radiology indicates that MRI of the shoulder without intravenous contrast is the preferred modality for evaluating rotator‑cuff pathology when surgical planning is anticipated. 9
MRI is especially recommended in patients with large body habitus, limited range of motion due to pain, or when intra‑articular pathology (e.g., labral tears) is suspected. 9
When MRI is contraindicated or when proximal humeral hardware would cause artifact, the American College of Radiology suggests ultrasound as an acceptable alternative. 9

Modality	Sensitivity for Full‑Thickness Tear	Specificity for Full‑Thickness Tear	Comments
MRI (non‑contrast)	90 % – 95 %	90 % – 95 %	High accuracy; also detects tendon retraction, muscle atrophy, and fatty infiltration that guide surgical decisions.
Ultrasound	90 % – 91 %	93 % – 95 %	Comparable to MRI for full‑thickness tears; limited for partial‑thickness tears and intra‑articular lesions.

The American College of Radiology reports that MRI’s high sensitivity and specificity (90‑95 %) for full‑thickness supraspinatus tears, together with its superior ability to assess tendon retraction, muscle atrophy, and fatty infiltration, make it the optimal choice for surgical planning. 10
The American College of Radiology notes that ultrasound provides equivalent performance to MRI for full‑thickness tears (sensitivity 90‑91 %, specificity 93‑95 %) but has variable inter‑observer agreement and is less reliable for partial‑thickness tears and intra‑articular pathology. 10

If conventional MRI or ultrasound yields equivocal results regarding tear depth, the American College of Radiology advises considering MR arthrography to better differentiate partial‑ from full‑thickness tears when the distinction would alter management. 9

The American College of Radiology cautions against omitting plain radiographs; proceeding directly to advanced imaging or treatment without them may miss fractures, dislocations, or other bony abnormalities that would fundamentally change patient management. 10