Shoulder PainAPPROACH

MUSCULOSKELETAL AND EXTREMITIES · 19 SECTIONS

⚲

528 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Shoulder Pain Elbow Pain Wrist Pain Hand Pain Hip Pain Knee Pain Ankle Pain Foot Pain Cast Or Splint Complication Symptoms Wound Check And Suture Related Visits Joint Swelling And Monoarthritis Suspected Septic Joint Presentation Suspected Tendon Rupture Presentation Limp Or Refusal To Bear Weight

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx69

Presenting features

›Shoulder pain history core

›Laterality

›Dominant arm

›Acute traumatic onset

›Atraumatic onset

›Overuse or repetitive activity

›Occupational exposures

›Sports exposures

›Prior episodes

›Baseline function and ROM

›Functional impact

›Sleep disruption

›Dressing and grooming limitation

›Work limitation

OPQRST

›Symptom characterization

›Onset

›Sudden

›Gradual

›Time since onset

›Provocation and palliation

›Worse with overhead activity

›Worse with reaching across body

›Worse with external rotation

›Worse at night

›Relief with rest

›Relief with NSAIDs

›Quality

›Sharp

›Dull

›Burning

›Clicking or catching sensation

›Region and radiation

›Anterior shoulder

›Lateral deltoid region

›Posterior shoulder

›Radiation to neck

›Radiation to arm

›Radiation to chest

›Radiation to scapula

›Severity

›Pain scale 0 to 10

›Weakness severity

›Timing

›Constant

›Intermittent

›With specific movements

›Morning stiffness duration

Associated symptoms

›Associated symptom screen

›Weakness

›Stiffness

›Decreased active ROM

›Decreased passive ROM

›Numbness or paresthesias

›Neck pain

›Fever

›Redness or warmth

›Swelling

›Chest pressure or dyspnea

›Cough or pleuritic pain

›Abdominal pain

Mechanism and context

›Context qualifiers

›Fall on outstretched hand

›Direct blow

›Traction injury

›Seizure or electrocution risk for posterior dislocation

›Recent injection or procedure

›Recent infection

›New exercise program

›New backpack or load carriage

02Alarm Features/alarm45

Approach to the critical patient

›First 5 minutes

›Airway concern

›SpO2 target 92 to 96 percent

›Cardiac monitor for unstable vitals

›IV access if hypotension or severe pain requiring parenteral meds

›Point of care glucose if altered mental status

›ECG within 10 minutes if concern for ACS equivalent

›Immediate ortho consult triggers

›Open fracture

›Irreducible dislocation

›Vascular compromise

›Immediate sepsis pathway triggers

›Fever with hot swollen joint

›Hypotension

Vital sign danger thresholds

›High risk physiology

›SBP under 90 mmHg

›HR 120 or higher

›RR 24 or higher

›SpO2 under 92 percent on room air

›Temp 38.0 C or higher with suspected joint infection

High risk historical triggers

›Cannot miss history elements

›Chest pain features

›Dyspnea or syncope

›Recent immobilization

›Recent surgery within 4 weeks

›Active cancer

›IVDU

›Immunocompromise

›Anticoagulant use

›Seizure with shoulder pain

High risk exam findings

›Red flag exam findings

›Deformity with loss of contour

›Inability to actively abduct after trauma

›Marked pain with any passive ROM

›Erythema and warmth over joint

›Neurovascular deficit

›Deltoid numbness

›Weak wrist or finger extension

›Diminished radial pulse

Immediate escalation triggers

›Escalate level of care when present

›Suspected ACS equivalent

›Suspected septic arthritis

›Suspected PE or pneumothorax

›Suspected compartment syndrome of upper arm

›Progressive neurologic deficit

03Medications/meds32

Medication reconciliation

›Current and recent meds

›Anticoagulants

›Antiplatelets

›Chronic steroids

›Diabetes meds

›Immunosuppressants

›Recent antibiotics

›Recent intraarticular steroid injection

High risk medication considerations

›Interaction and contraindication checks

›NSAID risk factors

›CKD

›Prior GI bleed

›Concurrent anticoagulant

›Opioid risk factors

›OSA

›Concurrent sedatives

ED analgesic options with adult doses

›Symptom control dosing examples

›Acetaminophen PO 1000 mg once

›Maximum 3000 mg per day for many adults

›Lower maximum with liver disease

›Ibuprofen PO 400 mg once

›Typical range 400 to 600 mg per dose

›Avoid in pregnancy third trimester

›Naproxen PO 500 mg once

›Typical 250 to 500 mg twice daily

›Avoid with high GI bleed risk

›Topical diclofenac gel

›Local protocol dependent availability

›Avoid on broken skin

›Lidocaine 4 percent patch

›Avoid on broken skin

›Local protocol dependent availability

04Diet/diet10

Intake and triggers

›Diet and hydration context

›Poor oral intake

›Dehydration symptoms

›Caffeine excess

›Energy drink exposure

›Alcohol exposure

Metabolic and inflammatory context

›Diet patterns relevant to inflammatory pain

›Recent crash dieting

›High purine intake risk for gout

›Low calcium and vitamin D risk context

05Review of Systems/ros25

Musculoskeletal

›MSK ROS

›Other joint pain

›Morning stiffness

›Back pain

›Myalgias

›Recent trauma

Neurologic

›Neuro ROS

›Neck pain

›Arm numbness

›Arm weakness

›Hand clumsiness

›Headache

Cardiopulmonary

›Cardiorespiratory ROS

›Chest pain

›Dyspnea

›Palpitations

›Syncope

›Cough

›Pleuritic pain

Infectious and systemic

›Systemic ROS

›Fever

›Chills

›Night sweats

›Unintentional weight loss

›Skin lesions or wounds near shoulder

06Collateral History and Family History/chafh14

Collateral and reliability

›Collateral sources

›Family or caregiver report

›EMS report

›Facility documentation

Family history

›Relevant familial conditions

›Early CAD in first degree relative

›Inflammatory arthritis

›Connective tissue disorders

›Ehlers-Danlos syndrome

›Marfan syndrome

Exposure context

›Household and contact context

›Sick contacts

›Recent travel

›Tick exposure in endemic regions

07Risk Factors/rf23

Trauma and structural risk

›Structural injury risks

›Older age fall risk

›Osteoporosis risk

›Prior shoulder dislocation

›Seizure disorder

Infection risk

›Septic joint and soft tissue infection risks

›Diabetes mellitus (E11.9)

›IVDU

›Immunosuppression

›Recent bacteremia

›Recent joint injection

Thrombosis and vascular risk

›Upper extremity thrombosis risks

›Central venous catheter or PICC

›Repetitive overhead activity

›Thoracic outlet anatomy history

Referred pain risk

›Non MSK sources of shoulder pain

›CAD risk factors

›HTN (I10)

›Hyperlipidemia (E78.5)

›Smoking history

›PE risks

›Recent immobilization

›Estrogen therapy

08Differential Diagnosis/ddx64

Life threatening

›Cannot miss diagnoses

›Acute coronary syndrome (I21.9)

›Left shoulder or arm pain with exertional features

›Associated dyspnea or diaphoresis

›Pulmonary embolism (I26.99)

›Pleuritic pain with dyspnea

›Tachycardia or hypoxemia

›Pneumothorax (J93.9)

›Sudden pleuritic pain with unilateral decreased breath sounds

›Hypotension concern for tension physiology

›Septic arthritis of shoulder (M00.9)

›Severe pain with passive ROM

›Fever or systemic toxicity

›Shoulder dislocation with vascular injury (S43.0)

›Diminished pulses

›Expanding hematoma

›Cervical spinal cord compression

›Progressive weakness

›Gait difficulty or bowel bladder changes

Common

›High probability outpatient pattern diagnoses

›Rotator cuff tendinopathy or tear (M75.1)

›Painful arc

›Weakness with abduction or external rotation

›Subacromial impingement (M75.4)

›Pain with overhead activity

›Neer or Hawkins positive

›Adhesive capsulitis (M75.0)

›Loss of active ROM

›Loss of passive ROM

›AC joint sprain or osteoarthritis (M19.019)

›Focal AC tenderness

›Cross body adduction pain

›Biceps tendinopathy (M75.2)

›Anterior shoulder pain

›Pain with Speed or Yergason maneuvers

›Cervical radiculopathy (M54.12)

›Neck pain with arm paresthesias

›Spurling reproduction

Less common

›Lower probability but important

›Calcific tendinitis (M65.2)

›Acute severe pain

›Limited ROM due to pain

›Glenohumeral osteoarthritis (M19.011)

›Chronic pain

›Crepitus

›Labral tear including SLAP lesion (S43.43)

›Clicking or catching

›Pain with overhead throwing

›Polymyalgia rheumatica (M35.3)

›Bilateral shoulder aching

›Morning stiffness over 45 minutes

›Herpes zoster (B02.9)

›Dermatomal pain before rash

›Allodynia

Mimics and zebras

›Mimics to keep in mind

›Pancoast tumor

›Shoulder pain with Horner syndrome features

›Weight loss or persistent cough

›Diaphragmatic irritation referred pain

›RUQ pain

›Splenic injury after trauma

›Thoracic outlet syndrome (G54.0)

›Symptoms with arm elevation

›Venous congestion or swelling

09Past Medical History/pmh16

Relevant conditions

›Key PMH elements

›Prior shoulder injury or surgery

›Prior dislocations or instability

›Rheumatologic disease

›Diabetes mellitus (E11.9)

›Chronic kidney disease (N18.9)

›CAD history

›Malignancy history

Procedures and devices

›Procedures and device history

›Recent injections near shoulder

›Indwelling central line or PICC

›Pacemaker or ICD for MRI screening

Baseline function

›Baseline status

›Independent ADLs

›Baseline ROM limitations

›Baseline neurologic deficits

10Physical Exam/exam39

General and vitals

›General assessment

›Toxic appearance

›Diaphoresis

›Fever pattern

›Pain behavior out of proportion

Shoulder inspection and palpation

›Local exam basics

›Deformity

›Ecchymosis

›Swelling

›Erythema

›Warmth

›Focal tenderness

›AC joint

›Bicipital groove

›Greater tuberosity

›Scapular spine

Range of motion

›ROM pattern

›Active ROM limitation

›Passive ROM limitation

›Painful arc 60 to 120 degrees

›External rotation limitation

Strength and neurovascular

›Neurovascular and strength

›Deltoid strength

›Supraspinatus strength

›External rotation strength

›Hand intrinsic strength

›Sensation over lateral deltoid

›Distal pulses

›Capillary refill

Adjacent systems

›Referred pain evaluation

›Neck exam

›Midline tenderness

›ROM limitation

›Cardiopulmonary exam

›New murmur

›Unilateral decreased breath sounds

›Abdominal exam

›RUQ tenderness

›LUQ tenderness after trauma

11Lab Studies/labs23

Initial labs by scenario

›Labs guided by pretest probability

›CBC for infection concern

›Leukocytosis support for infection

›Normal CBC does not exclude septic arthritis

›CRP and ESR for inflammatory or septic joint concern

›Elevated supports inflammation

›Normal early values do not exclude infection

›BMP for NSAID safety or systemic illness

›Creatinine baseline for medication choice

›Electrolytes for systemic illness

Cardiac and thromboembolic evaluation

›Non MSK source testing when indicated

›High sensitivity troponin for ACS concern

›Timing relative to symptom onset affects sensitivity

›Serial testing per local protocol

›D dimer for PE workup in low to intermediate risk patients

›Use only with validated pretest probability tool

›False positives common with inflammation and age

Infectious workup escalation

›If septic arthritis suspected

›Blood cultures before antibiotics when feasible

›Lactate if sepsis physiology

›Joint aspiration studies

›Synovial WBC count

›Gram stain and culture

12Imaging/img37

Scoring Systems

›Decision tools related to shoulder pain contexts

›Canadian C-Spine Rule for trauma with neck concern

›When to use

›Blunt trauma with potential cervical spine injury

›Alert patient

›When not to use

›Penetrating trauma

›Unstable vitals

›HEART score for possible ACS equivalent symptoms

›When to use

›Chest pain or anginal equivalent

›Troponin and ECG available

›When not to use

›STEMI on ECG

›Hemodynamic instability

MRI

›MRI indications and pearls

›Suspected full thickness rotator cuff tear with significant weakness

›Suspected labral pathology in athletes

›Suspected occult fracture with negative radiographs

›Suspected osteomyelitis or deep infection

›Contraindications and precautions

›Non MRI compatible implant

›Severe claustrophobia local protocol dependent

›CT use cases

›Complex proximal humerus fracture characterization

›Suspected scapular fracture not seen on X-ray

›CT pulmonary angiography for PE concern

›Contrast nephropathy risk assessment

›Radiation exposure consideration

›CT chest for suspected apical mass when indicated

Ultrasound

›Ultrasound applications

›POCUS for joint effusion detection

›Effusion supports septic arthritis possibility

›Absence of effusion does not exclude infection early

›Rotator cuff ultrasound by experienced operator

›Operator dependent accuracy

›Limited for labral pathology

13Special Tests/spec37

Rotator cuff and impingement maneuvers

›Bedside shoulder maneuvers

›Neer impingement test

›Pain with passive forward flexion in internal rotation

›Supports impingement pattern

›Hawkins-Kennedy test

›Pain with passive internal rotation at 90 degrees flexion

›Supports impingement pattern

›Empty can test

›Pain or weakness in scapular plane abduction

›Supports supraspinatus involvement

›Drop arm test

›Inability to slowly lower abducted arm

›Supports large rotator cuff tear

Biceps and labral maneuvers

›Biceps and labrum maneuvers

›Speed test

›Pain with resisted forward flexion

›Supports biceps tendinopathy

›Yergason test

›Pain with resisted supination

›Supports biceps tendon pathology

›OBrien active compression test

›Pain or clicking with resisted forward flexion and adduction

›Supports labral pathology

Instability and dislocation maneuvers

›Instability assessment

›Apprehension and relocation

›Apprehension with abduction and external rotation

›Relief with posteriorly directed force supports instability

›Sulcus sign

›Inferior translation suggests laxity

›Compare bilaterally

Cervical radiculopathy bedside tests

›Neck related tests

›Spurling test

›Reproduction of radicular symptoms supports radiculopathy

›Avoid if suspected cervical instability

›Arm squeeze test

›Pain more with mid arm squeeze than shoulder suggests cervical source

›Interpret with overall clinical context

14ECG/ecg9

Indications and interpretation

›ECG use in shoulder pain

›ECG for anginal equivalent symptoms

›ECG for unexplained diaphoresis or dyspnea

›Serial ECGs for evolving symptoms

›High risk ECG patterns

›STEMI criteria local protocol dependent

›New ischemic ST depression or T wave inversion

›New LBBB with ischemic symptoms

›Ventricular arrhythmia

15Assessment/ax14

Problem representation

›Working problem statement

›Traumatic shoulder pain

›Atraumatic shoulder pain

›Shoulder pain with systemic features

›Shoulder pain with neurologic features

Severity and risk stratification

›Risk features guiding urgency

›Suspected dislocation or fracture

›Suspected septic arthritis

›Suspected referred cardiopulmonary pain

›Progressive neurologic deficit

Diagnostic uncertainty handling

›Alternative diagnoses to keep active

›Cervical radiculopathy versus rotator cuff pathology

›Adhesive capsulitis versus severe pain limited ROM

›MSK pain versus ACS equivalent in high risk patient

16Plan/plan31

Analgesia and initial management

›Symptom control strategy

›Ice and activity modification short term

›Sling for comfort short term

›Avoid prolonged immobilization without clear indication

Diagnostic sequencing

›Testing pathway logic

›Trauma with deformity or focal bony tenderness

›Shoulder X-ray series

›CT if complex fracture suspected

›Hot swollen shoulder with severe pain on passive ROM

›Ultrasound for effusion support

›Arthrocentesis and antibiotics after cultures when feasible

›Neurologic symptoms or neck pain

›Cervical spine imaging per rule and exam

›MRI outpatient if persistent deficit local protocol dependent

›Concern for ACS equivalent

›ECG and troponin pathway per local protocol

›Treat as chest pain pathway if positive features

Condition specific treatment examples

›Dislocation management

›Reduction method per clinician skill and local protocol

›Post reduction neurovascular exam

›Post reduction X-ray confirmation

›Suspected septic arthritis initial antimicrobials after aspiration when feasible

›Vancomycin IV dosing weight based local protocol dependent

›Ceftriaxone IV 2 g once daily when gram negative coverage needed local protocol dependent

›Suspected inflammatory bursitis or tendinopathy

›NSAIDs if no contraindications

›Early outpatient PT referral

Monitoring and reassessment

›Reassessment loop

›Pain reassessment within 30 to 60 minutes after treatment

›Neurovascular reassessment after splinting or reduction

›Repeat vitals if systemic concern

17Disposition/dispo19

Admission and higher level care criteria

›Inpatient criteria

›Suspected septic arthritis

›Uncontrolled pain requiring parenteral analgesia

›Neurovascular compromise

›Complicated fracture requiring operative planning

›ICU or stepdown criteria

›Sepsis physiology

›Hemodynamic instability

›High risk ACS or PE

Discharge criteria

›Safe discharge features

›No red flags on history and exam

›Neurovascularly intact

›Pain controlled with oral regimen

›Clear outpatient plan

Follow up timing

›Follow up windows

›Orthopedics within 3 to 7 days for dislocation or fracture

›Primary care within 1 to 2 weeks for atraumatic pain

›Physio within 1 to 2 weeks when indicated

›Immediate return if worsening neurovascular symptoms

18Discharge Instructions/di15

Copy discharge instructions

›Shoulder pain discharge guidance

›Most shoulder pain is from muscles, tendons, or joints and improves with time and gentle movement

›Use ice 15 to 20 minutes up to 4 times daily for the first 48 hours if helpful

›Use a sling only for comfort and try gentle shoulder range of motion as tolerated unless told otherwise

›Pain medicines as prescribed

›Avoid heavy lifting and overhead activity until improving

›Follow up with your clinician or physiotherapy within the recommended time window

›Return to the ER now for

›New chest pain

›Trouble breathing

›Fever

›Redness and warmth with rapidly worsening pain

›New numbness or weakness in the arm or hand

›Cold or pale hand

›Severe swelling of the arm

19References/r6

Guidelines and core sources

›Evidence sources for shoulder pain evaluation

›American Academy of Orthopaedic Surgeons clinical practice guideline on rotator cuff injuries most recent version local protocol dependent

›American College of Radiology Appropriateness Criteria shoulder pain most recent version

›Infectious Diseases Society of America guidance for septic arthritis and osteomyelitis most recent version local protocol dependent

›American Heart Association and American College of Cardiology guideline for chest pain evaluation 2021

›Canadian C-Spine Rule derivation and validation studies

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.

Shoulder PainAPPROACH

MUSCULOSKELETAL AND EXTREMITIES · 19 SECTIONS

⚲

528 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx69

Presenting features

›Shoulder pain history core

›Laterality

›Dominant arm

›Acute traumatic onset

›Atraumatic onset

›Overuse or repetitive activity

›Occupational exposures

›Sports exposures

›Prior episodes

›Baseline function and ROM

›Functional impact

›Sleep disruption

›Dressing and grooming limitation

›Work limitation

OPQRST

›Symptom characterization

›Onset

›Sudden

›Gradual

›Time since onset

›Provocation and palliation

›Worse with overhead activity

›Worse with reaching across body

›Worse with external rotation

›Worse at night

›Relief with rest

›Relief with NSAIDs

›Quality

›Sharp

›Dull

›Burning

›Clicking or catching sensation

›Region and radiation

›Anterior shoulder

›Lateral deltoid region

›Posterior shoulder

›Radiation to neck

›Radiation to arm

›Radiation to chest

›Radiation to scapula

›Severity

›Pain scale 0 to 10

›Weakness severity

›Timing

›Constant

›Intermittent

›With specific movements

›Morning stiffness duration

Associated symptoms

›Associated symptom screen

›Weakness

›Stiffness

›Decreased active ROM

›Decreased passive ROM

›Numbness or paresthesias

›Neck pain

›Fever

›Redness or warmth

›Swelling

›Chest pressure or dyspnea

›Cough or pleuritic pain

›Abdominal pain

Mechanism and context

›Context qualifiers

›Fall on outstretched hand

›Direct blow

›Traction injury

›Seizure or electrocution risk for posterior dislocation

›Recent injection or procedure

›Recent infection

›New exercise program

›New backpack or load carriage

02Alarm Features/alarm45

Approach to the critical patient

›First 5 minutes

›Airway concern

›SpO2 target 92 to 96 percent

›Cardiac monitor for unstable vitals

›IV access if hypotension or severe pain requiring parenteral meds

›Point of care glucose if altered mental status

›ECG within 10 minutes if concern for ACS equivalent

›Immediate ortho consult triggers

›Open fracture

›Irreducible dislocation

›Vascular compromise

›Immediate sepsis pathway triggers

›Fever with hot swollen joint

›Hypotension

Vital sign danger thresholds

›High risk physiology

›SBP under 90 mmHg

›HR 120 or higher

›RR 24 or higher

›SpO2 under 92 percent on room air

›Temp 38.0 C or higher with suspected joint infection

High risk historical triggers

›Cannot miss history elements

›Chest pain features

›Dyspnea or syncope

›Recent immobilization

›Recent surgery within 4 weeks

›Active cancer

›IVDU

›Immunocompromise

›Anticoagulant use

›Seizure with shoulder pain

High risk exam findings

›Red flag exam findings

›Deformity with loss of contour

›Inability to actively abduct after trauma

›Marked pain with any passive ROM

›Erythema and warmth over joint

›Neurovascular deficit

›Deltoid numbness

›Weak wrist or finger extension

›Diminished radial pulse

Immediate escalation triggers

›Escalate level of care when present

›Suspected ACS equivalent

›Suspected septic arthritis

›Suspected PE or pneumothorax

›Suspected compartment syndrome of upper arm

›Progressive neurologic deficit

03Medications/meds32

Medication reconciliation

›Current and recent meds

›Anticoagulants

›Antiplatelets

›Chronic steroids

›Diabetes meds

›Immunosuppressants

›Recent antibiotics

›Recent intraarticular steroid injection

High risk medication considerations

›Interaction and contraindication checks

›NSAID risk factors

›CKD

›Prior GI bleed

›Concurrent anticoagulant

›Opioid risk factors

›OSA

›Concurrent sedatives

ED analgesic options with adult doses

›Symptom control dosing examples

›Acetaminophen PO 1000 mg once

›Maximum 3000 mg per day for many adults

›Lower maximum with liver disease

›Ibuprofen PO 400 mg once

›Typical range 400 to 600 mg per dose

›Avoid in pregnancy third trimester

›Naproxen PO 500 mg once

›Typical 250 to 500 mg twice daily

›Avoid with high GI bleed risk

›Topical diclofenac gel

›Local protocol dependent availability

›Avoid on broken skin

›Lidocaine 4 percent patch

›Avoid on broken skin

›Local protocol dependent availability

04Diet/diet10

Intake and triggers

›Diet and hydration context

›Poor oral intake

›Dehydration symptoms

›Caffeine excess

›Energy drink exposure

›Alcohol exposure

Metabolic and inflammatory context

›Diet patterns relevant to inflammatory pain

›Recent crash dieting

›High purine intake risk for gout

›Low calcium and vitamin D risk context

05Review of Systems/ros25

Musculoskeletal

›MSK ROS

›Other joint pain

›Morning stiffness

›Back pain

›Myalgias

›Recent trauma

Neurologic

›Neuro ROS

›Neck pain

›Arm numbness

›Arm weakness

›Hand clumsiness

›Headache

Cardiopulmonary

›Cardiorespiratory ROS

›Chest pain

›Dyspnea

›Palpitations

›Syncope

›Cough

›Pleuritic pain

Infectious and systemic

›Systemic ROS

›Fever

›Chills

›Night sweats

›Unintentional weight loss

›Skin lesions or wounds near shoulder

06Collateral History and Family History/chafh14

Collateral and reliability

›Collateral sources

›Family or caregiver report

›EMS report

›Facility documentation

Family history

›Relevant familial conditions

›Early CAD in first degree relative

›Inflammatory arthritis

›Connective tissue disorders

›Ehlers-Danlos syndrome

›Marfan syndrome

Exposure context

›Household and contact context

›Sick contacts

›Recent travel

›Tick exposure in endemic regions

07Risk Factors/rf23

Trauma and structural risk

›Structural injury risks

›Older age fall risk

›Osteoporosis risk

›Prior shoulder dislocation

›Seizure disorder

Infection risk

›Septic joint and soft tissue infection risks

›Diabetes mellitus (E11.9)

›IVDU

›Immunosuppression

›Recent bacteremia

›Recent joint injection

Thrombosis and vascular risk

›Upper extremity thrombosis risks

›Central venous catheter or PICC

›Repetitive overhead activity

›Thoracic outlet anatomy history

Referred pain risk

›Non MSK sources of shoulder pain

›CAD risk factors

›HTN (I10)

›Hyperlipidemia (E78.5)

›Smoking history

›PE risks

›Recent immobilization

›Estrogen therapy

08Differential Diagnosis/ddx64

Life threatening

›Cannot miss diagnoses

›Acute coronary syndrome (I21.9)

›Left shoulder or arm pain with exertional features

›Associated dyspnea or diaphoresis

›Pulmonary embolism (I26.99)

›Pleuritic pain with dyspnea

›Tachycardia or hypoxemia

›Pneumothorax (J93.9)

›Sudden pleuritic pain with unilateral decreased breath sounds

›Hypotension concern for tension physiology

›Septic arthritis of shoulder (M00.9)

›Severe pain with passive ROM

›Fever or systemic toxicity

›Shoulder dislocation with vascular injury (S43.0)

›Diminished pulses

›Expanding hematoma

›Cervical spinal cord compression

›Progressive weakness

›Gait difficulty or bowel bladder changes

Common

›High probability outpatient pattern diagnoses

›Rotator cuff tendinopathy or tear (M75.1)

›Painful arc

›Weakness with abduction or external rotation

›Subacromial impingement (M75.4)

›Pain with overhead activity

›Neer or Hawkins positive

›Adhesive capsulitis (M75.0)

›Loss of active ROM

›Loss of passive ROM

›AC joint sprain or osteoarthritis (M19.019)

›Focal AC tenderness

›Cross body adduction pain

›Biceps tendinopathy (M75.2)

›Anterior shoulder pain

›Pain with Speed or Yergason maneuvers

›Cervical radiculopathy (M54.12)

›Neck pain with arm paresthesias

›Spurling reproduction

Less common

›Lower probability but important

›Calcific tendinitis (M65.2)

›Acute severe pain

›Limited ROM due to pain

›Glenohumeral osteoarthritis (M19.011)

›Chronic pain

›Crepitus

›Labral tear including SLAP lesion (S43.43)

›Clicking or catching

›Pain with overhead throwing

›Polymyalgia rheumatica (M35.3)

›Bilateral shoulder aching

›Morning stiffness over 45 minutes

›Herpes zoster (B02.9)

›Dermatomal pain before rash

›Allodynia

Mimics and zebras

›Mimics to keep in mind

›Pancoast tumor

›Shoulder pain with Horner syndrome features

›Weight loss or persistent cough

›Diaphragmatic irritation referred pain

›RUQ pain

›Splenic injury after trauma

›Thoracic outlet syndrome (G54.0)

›Symptoms with arm elevation

›Venous congestion or swelling

09Past Medical History/pmh16

Relevant conditions

›Key PMH elements

›Prior shoulder injury or surgery

›Prior dislocations or instability

›Rheumatologic disease

›Diabetes mellitus (E11.9)

›Chronic kidney disease (N18.9)

›CAD history

›Malignancy history

Procedures and devices

›Procedures and device history

›Recent injections near shoulder

›Indwelling central line or PICC

›Pacemaker or ICD for MRI screening

Baseline function

›Baseline status

›Independent ADLs

›Baseline ROM limitations

›Baseline neurologic deficits

10Physical Exam/exam39

General and vitals

›General assessment

›Toxic appearance

›Diaphoresis

›Fever pattern

›Pain behavior out of proportion

Shoulder inspection and palpation

›Local exam basics

›Deformity

›Ecchymosis

›Swelling

›Erythema

›Warmth

›Focal tenderness

›AC joint

›Bicipital groove

›Greater tuberosity

›Scapular spine

Range of motion

›ROM pattern

›Active ROM limitation

›Passive ROM limitation

›Painful arc 60 to 120 degrees

›External rotation limitation

Strength and neurovascular

›Neurovascular and strength

›Deltoid strength

›Supraspinatus strength

›External rotation strength

›Hand intrinsic strength

›Sensation over lateral deltoid

›Distal pulses

›Capillary refill

Adjacent systems

›Referred pain evaluation

›Neck exam

›Midline tenderness

›ROM limitation

›Cardiopulmonary exam

›New murmur

›Unilateral decreased breath sounds

›Abdominal exam

›RUQ tenderness

›LUQ tenderness after trauma

11Lab Studies/labs23

Initial labs by scenario

›Labs guided by pretest probability

›CBC for infection concern

›Leukocytosis support for infection

›Normal CBC does not exclude septic arthritis

›CRP and ESR for inflammatory or septic joint concern

›Elevated supports inflammation

›Normal early values do not exclude infection

›BMP for NSAID safety or systemic illness

›Creatinine baseline for medication choice

›Electrolytes for systemic illness

Cardiac and thromboembolic evaluation

›Non MSK source testing when indicated

›High sensitivity troponin for ACS concern

›Timing relative to symptom onset affects sensitivity

›Serial testing per local protocol

›D dimer for PE workup in low to intermediate risk patients

›Use only with validated pretest probability tool

›False positives common with inflammation and age

Infectious workup escalation

›If septic arthritis suspected

›Blood cultures before antibiotics when feasible

›Lactate if sepsis physiology

›Joint aspiration studies

›Synovial WBC count

›Gram stain and culture

12Imaging/img37

Scoring Systems

›Decision tools related to shoulder pain contexts

›Canadian C-Spine Rule for trauma with neck concern

›When to use

›Blunt trauma with potential cervical spine injury

›Alert patient

›When not to use

›Penetrating trauma

›Unstable vitals

›HEART score for possible ACS equivalent symptoms

›When to use

›Chest pain or anginal equivalent

›Troponin and ECG available

›When not to use

›STEMI on ECG

›Hemodynamic instability

MRI

›MRI indications and pearls

›Suspected full thickness rotator cuff tear with significant weakness

›Suspected labral pathology in athletes

›Suspected occult fracture with negative radiographs

›Suspected osteomyelitis or deep infection

›Contraindications and precautions

›Non MRI compatible implant

›Severe claustrophobia local protocol dependent

›CT use cases

›Complex proximal humerus fracture characterization

›Suspected scapular fracture not seen on X-ray

›CT pulmonary angiography for PE concern

›Contrast nephropathy risk assessment

›Radiation exposure consideration

›CT chest for suspected apical mass when indicated

Ultrasound

›Ultrasound applications

›POCUS for joint effusion detection

›Effusion supports septic arthritis possibility

›Absence of effusion does not exclude infection early

›Rotator cuff ultrasound by experienced operator

›Operator dependent accuracy

›Limited for labral pathology

13Special Tests/spec37

Rotator cuff and impingement maneuvers

›Bedside shoulder maneuvers

›Neer impingement test

›Pain with passive forward flexion in internal rotation

›Supports impingement pattern

›Hawkins-Kennedy test

›Pain with passive internal rotation at 90 degrees flexion

›Supports impingement pattern

›Empty can test

›Pain or weakness in scapular plane abduction

›Supports supraspinatus involvement

›Drop arm test

›Inability to slowly lower abducted arm

›Supports large rotator cuff tear

Biceps and labral maneuvers

›Biceps and labrum maneuvers

›Speed test

›Pain with resisted forward flexion

›Supports biceps tendinopathy

›Yergason test

›Pain with resisted supination

›Supports biceps tendon pathology

›OBrien active compression test

›Pain or clicking with resisted forward flexion and adduction

›Supports labral pathology

Instability and dislocation maneuvers

›Instability assessment

›Apprehension and relocation

›Apprehension with abduction and external rotation

›Relief with posteriorly directed force supports instability

›Sulcus sign

›Inferior translation suggests laxity

›Compare bilaterally

Cervical radiculopathy bedside tests

›Neck related tests

›Spurling test

›Reproduction of radicular symptoms supports radiculopathy

›Avoid if suspected cervical instability

›Arm squeeze test

›Pain more with mid arm squeeze than shoulder suggests cervical source

›Interpret with overall clinical context

14ECG/ecg9

Indications and interpretation

›ECG use in shoulder pain

›ECG for anginal equivalent symptoms

›ECG for unexplained diaphoresis or dyspnea

›Serial ECGs for evolving symptoms

›High risk ECG patterns

›STEMI criteria local protocol dependent

›New ischemic ST depression or T wave inversion

›New LBBB with ischemic symptoms

›Ventricular arrhythmia

15Assessment/ax14

Problem representation

›Working problem statement

›Traumatic shoulder pain

›Atraumatic shoulder pain

›Shoulder pain with systemic features

›Shoulder pain with neurologic features

Severity and risk stratification

›Risk features guiding urgency

›Suspected dislocation or fracture

›Suspected septic arthritis

›Suspected referred cardiopulmonary pain

›Progressive neurologic deficit

Diagnostic uncertainty handling

›Alternative diagnoses to keep active

›Cervical radiculopathy versus rotator cuff pathology

›Adhesive capsulitis versus severe pain limited ROM

›MSK pain versus ACS equivalent in high risk patient

16Plan/plan31

Analgesia and initial management

›Symptom control strategy

›Ice and activity modification short term

›Sling for comfort short term

›Avoid prolonged immobilization without clear indication

Diagnostic sequencing

›Testing pathway logic

›Trauma with deformity or focal bony tenderness

›Shoulder X-ray series

›CT if complex fracture suspected

›Hot swollen shoulder with severe pain on passive ROM

›Ultrasound for effusion support

›Arthrocentesis and antibiotics after cultures when feasible

›Neurologic symptoms or neck pain

›Cervical spine imaging per rule and exam

›MRI outpatient if persistent deficit local protocol dependent

›Concern for ACS equivalent

›ECG and troponin pathway per local protocol

›Treat as chest pain pathway if positive features

Condition specific treatment examples

›Dislocation management

›Reduction method per clinician skill and local protocol

›Post reduction neurovascular exam

›Post reduction X-ray confirmation

›Suspected septic arthritis initial antimicrobials after aspiration when feasible

›Vancomycin IV dosing weight based local protocol dependent

›Ceftriaxone IV 2 g once daily when gram negative coverage needed local protocol dependent

›Suspected inflammatory bursitis or tendinopathy

›NSAIDs if no contraindications

›Early outpatient PT referral

Monitoring and reassessment

›Reassessment loop

›Pain reassessment within 30 to 60 minutes after treatment

›Neurovascular reassessment after splinting or reduction

›Repeat vitals if systemic concern

17Disposition/dispo19

Admission and higher level care criteria

›Inpatient criteria

›Suspected septic arthritis

›Uncontrolled pain requiring parenteral analgesia

›Neurovascular compromise

›Complicated fracture requiring operative planning

›ICU or stepdown criteria

›Sepsis physiology

›Hemodynamic instability

›High risk ACS or PE

Discharge criteria

›Safe discharge features

›No red flags on history and exam

›Neurovascularly intact

›Pain controlled with oral regimen

›Clear outpatient plan

Follow up timing

›Follow up windows

›Orthopedics within 3 to 7 days for dislocation or fracture

›Primary care within 1 to 2 weeks for atraumatic pain

›Physio within 1 to 2 weeks when indicated

›Immediate return if worsening neurovascular symptoms

18Discharge Instructions/di15

Copy discharge instructions

›Shoulder pain discharge guidance

›Most shoulder pain is from muscles, tendons, or joints and improves with time and gentle movement

›Use ice 15 to 20 minutes up to 4 times daily for the first 48 hours if helpful

›Use a sling only for comfort and try gentle shoulder range of motion as tolerated unless told otherwise

›Pain medicines as prescribed

›Avoid heavy lifting and overhead activity until improving

›Follow up with your clinician or physiotherapy within the recommended time window

›Return to the ER now for

›New chest pain

›Trouble breathing

›Fever

›Redness and warmth with rapidly worsening pain

›New numbness or weakness in the arm or hand

›Cold or pale hand

›Severe swelling of the arm

19References/r6

Guidelines and core sources

›Evidence sources for shoulder pain evaluation

›American Academy of Orthopaedic Surgeons clinical practice guideline on rotator cuff injuries most recent version local protocol dependent

›American College of Radiology Appropriateness Criteria shoulder pain most recent version

›Infectious Diseases Society of America guidance for septic arthritis and osteomyelitis most recent version local protocol dependent

›American Heart Association and American College of Cardiology guideline for chest pain evaluation 2021

›Canadian C-Spine Rule derivation and validation studies

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.