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The location of the shoulder and its wide range of motion place it at risk for traumatic and nontraumatic injuries to the bony and soft tissue structures. Clavicle and proximal humerus fractures account for 12% and 4% to 6% of fractures in adults, respectively. 1 Shoulder pain is common and affects 5% to 47% of adults each year. 2 Acute shoulder pain lasting less than six months is a common presentation to primary care. The initial approach to acute shoulder injuries starts with a comprehensive history to understand the mechanism of injury and a complete shoulder examination to localize the injury. 3,4
SORT: KEY RECOMMENDATIONS FOR PRACTICE
| Clinical recommendation | Evidence rating | Comments |
|---|---|---|
| Use plain radiography as the recommended initial imaging modality for traumatic shoulder injuries to rule out fracture. 10 | C | Consistent evidence from cohort studies |
| Consider surgery in active patients younger than 25 years with anterior shoulder dislocation. 23–26 | B | Consistent evidence from cohort studies showing a lower rate of recurrence after surgery |
| Encourage nonoperative treatment of proximal humerus fractures in older patients. 36 | B | Consistent evidence from cohort studies showing fewer complications and better or equivalent outcomes compared with surgical management |
| Use ultrasonography or magnetic resonance imaging to detect complete rotator cuff tears. They have similar sensitivity and specificity. 37,42,45–47 | C | Limited evidence from randomized controlled trials showing skilled ultrasonography is equivalent to magnetic resonance imaging in detecting full-thickness rotator cuff tears but less accurate at identifying damage to deep structures; magnetic resonance imaging and ultrasonography are less sensitive for partial tears |
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.
BEST PRACTICES IN ORTHOPEDICS
Recommendations From Choosing Wisely
| Recommendation | Sponsoring organization |
|---|---|
| Consider evaluating rotator cuff tears with ultrasonography before ordering magnetic resonance imaging. | American Medical Society for Sports Medicine |
| Avoid routine use of opioids for treatment of knee or hip osteoarthritis, low back pain, or rotator cuff injury. | American Academy of Orthopaedic Surgeons |
Source: For more information on Choosing Wisely, see https://www.choosingwisely.org. For supporting citations and to search Choosing Wisely recommendations relevant to primary care, see https://www.aafp.org/pubs/afp/collections/choosing-wisely.html.
Initial Evaluation
The initial evaluation should include a...