Evaluation of Shoulder Pain

Initial Clinical Assessment

The American College of Physicians recommends starting with plain radiographs (minimum 3 views: AP, Grashey, and axillary or scapular Y) as the initial imaging for all patients presenting with shoulder pain, regardless of mechanism 1
Red flags requiring urgent evaluation include fever with joint effusion suggesting septic arthritis, acute neurologic deficits, suspected cardiac or pulmonary pathology causing referred pain, and acute trauma with suspected fracture or dislocation 1
Patients under 35 years with shoulder pain are primarily concerned with labral tears and glenohumeral instability, with key historical features including recurrent subluxation, "dead arm" sensation, or mechanical symptoms 1
The physical examination priorities for shoulder pain evaluation include assessing tone, strength, soft tissue length changes, and joint alignment of the shoulder girdle, as well as range of motion in all planes 2

If a fracture is identified, a CT without contrast is recommended to characterize fracture complexity, displacement, and aid surgical planning 1
For suspected instability or dislocation, an MRI without IV contrast is the primary study, while a CT without contrast may be considered when bone loss assessment is critical for surgical planning 1
For suspected labral tears, MR arthrography is the reference standard in subacute or chronic settings, while MRI without contrast is preferred in acute trauma 1
For suspected rotator cuff tears, MRI without contrast or ultrasound are equivalent first-line studies, with the choice depending on local expertise and availability 1

The American Academy of Orthopaedic Surgeons recommends NSAIDs such as ibuprofen 400-800 mg three to four times daily for pharmacologic management of shoulder pain 1
Acetaminophen is recommended for pain relief when no contraindications exist, according to the American Heart Association 2
Neuromodulating medications such as gabapentin or pregabalin are recommended when neuropathic features are present, including electric shock sensations, sensory changes, allodynia, or hyperpathia 3, 1
Gentle stretching and mobilization techniques are recommended for physical therapy, focusing on increasing external rotation and abduction, according to the American Physical Therapy Association 2

Neuropathic symptoms should not be dismissed as "normal postoperative pain" and require specific evaluation for nerve pathology and targeted treatment with neuromodulating agents rather than just NSAIDs 3
MR arthrography should not be ordered in the acute postoperative setting, and standard MRI without contrast is sufficient and appropriate 3
Initial radiographs should not be skipped, as they are essential for all presentations before advanced imaging, according to the American College of Radiology 1
Urgent referral should not be delayed for red flag diagnoses, including septic arthritis, acute neurologic deficits, or fractures requiring fixation 1