Appropriate Workup for Left Shoulder Pain

Initial Evaluation

The American College of Radiology recommends radiography as the preferred initial imaging modality for evaluating left shoulder pain, with a standard set of shoulder radiographs including anteroposterior (AP) views in internal and external rotation and an axillary or scapula-Y view 1, 2
Standard radiographic evaluation should include at least three views, with two being orthogonal, including anteroposterior (AP) views in internal and external rotation and an axillary lateral view or scapular Y view, which is essential for detecting dislocations 2, 1
Radiographs should be performed upright, as shoulder malalignment can be underrepresented on supine imaging 1

If radiographs are noncontributory and labral tear/instability is suspected, especially in patients under 35 years, the American College of Radiology recommends MR arthrography as the gold standard, with a rating of 9/9 for appropriateness 2, 3
For suspected rotator cuff pathology after noncontributory radiographs, MRI without contrast or ultrasound are recommended, both with a rating of 9/9, depending on local expertise 4
For suspected fractures requiring better characterization, CT provides superior fracture pattern delineation and is particularly valuable for preoperative planning of complex fractures 1, 5

For suspected septic arthritis, the American College of Radiology recommends ultrasound or fluoroscopic-guided arthrocentesis, with a rating of 9/9, and aspiration and fluid analysis are essential for diagnosis 4
When evaluating post-surgical shoulders, MRI, MR arthrography, and ultrasound are all appropriate, depending on local expertise, with a rating of 9/9 4

Axillary or scapula-Y views are vital in evaluating traumatic shoulder injuries, as acromioclavicular and glenohumeral dislocations can be misclassified on AP views alone 1
MR arthrography is superior to standard MRI for evaluating intra-articular pathology such as labral tears and capsular injuries 3
Most soft-tissue injuries can undergo conservative management initially, while unstable fractures and joint instability often require acute surgical intervention 1