Absence of effusion does not exclude infection early
Rotator cuff ultrasound by experienced operator
Operator dependent accuracy
Limited for labral pathology
Special Tests
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
ECG
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
Assessment
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
Plan
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
Disposition
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
Discharge Instructions
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
References
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
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.