Management of Acute Shoulder Injury

Initial Diagnostic Approach

The American College of Radiology recommends beginning with standard shoulder radiographs, including AP views in internal and external rotation, plus axillary or scapula-Y view, to rule out fracture or dislocation 1
Radiography is mandatory as the first imaging study for any traumatic shoulder injury to identify fractures and shoulder malalignment, which are the primary concerns requiring immediate intervention 1
The standard trauma series must include AP views in both internal and external rotation, axillary or scapula-Y view, and upright positioning when possible 1

The American Academy of Physical Medicine and Rehabilitation suggests that rotator cuff injury is the most likely diagnosis given weakness with overhead motion and pain with range of motion 2, 3
Pain with overhead lifting specifically indicates rotator cuff pathology, as this motion requires supraspinatus function and intact rotator cuff mechanics 2, 3

The American College of Radiology recommends that most soft-tissue shoulder injuries, including rotator cuff tears and labral tears, should undergo a period of conservative management before considering surgery 1
Complete rest from all overhead activities and lifting is mandatory until the patient is asymptomatic, followed by a structured rehabilitation program targeting rotator cuff and scapular stabilizers 2, 3, 5
The rehabilitation program should include rotator cuff strengthening, scapular stabilizer strengthening, and re-establishing proper shoulder and spine mechanics 2, 3, 7

Progress to loaded activities only when all criteria are met, including pain-free performance of current exercises, full active range of motion, no increase in resting pain or night pain, and proper scapular mechanics demonstrated during movement 5

If symptoms persist or progress despite 3-6 months of appropriate rehabilitation, obtain MRI and surgical consultation 5
Earlier imaging may be warranted if significant weakness persists beyond 2-4 weeks despite rest, complete inability to perform overhead activities after initial rest period, or suspicion of complete rotator cuff tear based on profound weakness 2, 3

If anterior dislocation is suspected, rehabilitation must aggressively target external rotator strengthening to address muscular imbalance 4
If rotator cuff tear is confirmed, strong evidence shows physical therapy improves patient-reported outcomes, though surgical repair shows superior outcomes when tears are small to medium-sized and successfully healed 5

Unstable or significantly displaced fracture on radiographs requires acute surgical management 1
Joint instability or dislocation requires acute reduction and surgical evaluation 1
Progressive neurological symptoms may indicate nerve injury requiring urgent evaluation 4