Published: April 6, 2026
A standardized primary care approach to knee and shoulder conditions — X-rays, a couple months of physical therapy followed by possible MRI and maybe referral to orthopedics — can prevent chronic disability as well as unnecessary imaging and referrals, according to Nyagon G. Duany, M.D., an orthopedic surgeon and sports medicine specialist with Norton Orthopedic Institute.
Key to following this framework involves knowing what you’re looking at, how to examine it properly and when to deviate from the standard pathway, according to Dr. Duany.
Start with plain films and order them with three views, not the standard two-view series that typically gets ordered.
Order: Weight-bearing sunrise, weight-bearing anteroposterior (AP) and lateral.
The sunrise view is the one that always gets left out, but it’s critical for evaluating patellar alignment. If someone complains of anterior knee pain with prolonged sitting or driving, this view shows whether the kneecap is maltracking.
The weight-bearing AP reveals the true severity of arthritis. Moderate arthritis on non-weight-bearing films reveal bone-on-bone contact when the patient stands.
“We want to get those weightbearing views (as long as the patient is able and there’s no fracture concern) so we can actually see the space in the joint at real time, because that’s going to dictate what we do,” Dr. Duany said.
The lateral view completes the series and can be done weight-bearing or supine.
Critical decision point: If weight-bearing films show severe arthritis, stop there. Don’t order an MRI.
“If you see severe arthritis on their weight-bearing view, don’t order an MRI, because the issue is arthritis and not a meniscal or ligamentous issue,” Dr. Duany said.Severe arthritis inevitably includes degenerative meniscal tears that don’t benefit from surgery. Treat the arthritis instead.
Order: AP, Y view (lateral scapular) and axillary.
The axillary view frequently gets omitted but shows glenohumeral joint alignment — essential for identifying dislocations.
The AP view reveals rotator cuff arthropathy through superior migration of the humeral head. When the rotator cuff is intact, it holds the ball centered in the socket. When it’s gone, the ball migrates upward.
The Y view demonstrates acromial bone spurs and calcific tendonitis.
The physical exam narrows your diagnosis and, critically, determines whether you can get an MRI authorized.
“The provocative tests are what’s important,” Dr. Duany said. “It’s going to help narrow the diagnosis, and also it’s what’s going to get the MRI approved.”
Get patients in shorts. Yes, they grumble in winter, but bilateral comparison is essential. Check range of motion (0 to 130 degrees), then move to provocative tests.
What you’re sorting out:
Patellofemoral pain (the most common knee complaint under age 60): Anterior knee pain with stairs, prolonged sitting, long car rides. Patients say, “It hurts when I sit in the movie theater.” The issue is patellar maltracking.“I always tell the patients, ‘you’ve been bending your knee for 50 years. If you don’t keep your muscles strong, it’s going to slip out of grooves where it meets the end of the femur and maltrack,’” Dr. Duany said.
Arthritis (most common over age 55): Morning stiffness that improves initially, then worsens with prolonged walking.
Meniscal injury: Catching, locking, the knee “stops”; during extension.
Anterior cruciate ligament (ACL) injury: Instability, knee gives out with directional changes.
Tip: Always start McMurray with the knee flexed — that’s the easy part to remember. For medial meniscus (most common), externally rotate and apply valgus. Sometimes you get just pain on deep palpation rather than a click —document it as a positive test.
Get patients in sleeveless shirts or gowns for bilateral shoulder comparison. Check range of motion: forward flexion and abduction to 160 degrees, external rotation to 60 to 80 degrees, internal rotation by having them reach behind their back.
Rotator cuff pathology (accounts for 44% to 65% of shoulder complaints): Insidious onset pain with overhead activity. The hallmark is night pain. Weakness suggests a tear rather than tendonitis. According to Dr. Duany, “bursitis, tendonitis and impingement are all the same pathophysiology in the rotator cuff system.”
Frozen shoulder: Global stiffness in all directions. The key finding is that active and passive range of motion are the same — true capsular restriction. Particularly common in diabetics.
Biceps tendon rupture: The “Popeye” deformity. Most don’t need surgery — they get better with physical therapy and time.
Documentation tip: Dr. Duany distinguished “painful empty can test”; (good strength but pain, suggesting tendonitis) from “positive empty can test”; (weakness, suggesting tear).
Most knee and shoulder conditions respond to conservative management.“Physical therapy is the biggest thing,” Dr. Duany said. “It really helps to strengthen muscles, stabilize the knee joint, and especially for patellofemoral, that is key.“A lot of people get better without even seeing us.”
Initial measures: RICE (rest, ice, compression, elevation) protocol, nonsteroidal anti-inflammatory drugs, activity modification. Bracing for knees if ambulation is painful.
Physical therapy: The cornerstone of treatment. Addresses the underlying muscle imbalance, tendon imbalance and ligament imbalance causing dysfunction.
Injections: Use when pain limits function or physical therapy participation. They buy time, reduce pain, and allow physical therapy to work more effectively.
Standard mixture for both knee and shoulder: 5 milliliters total (1 milliliter Kenalog, 2 milliliters of 1% to 2% lidocaine, 2 milliliters of 0.25% Marcaine)
Knee injection (lateral approach):
Patient sitting, knee flexed. Palpate the lateral joint line. For large knees, first find the inferior pole of the patella (hard bone you can always palpate), then slide laterally to the soft spot. Mark it with the blunt syringe tip. Clean the area, apply ethyl chloride if available. Insert the needle at your mark, directing it downward and toward the intercondylar notch — not straight lateral into the femoral condyle, which causes the “You hit my bone!” reaction. The injection should flow smoothly; if not, back up and redirect.
Shoulder injection (subacromial approach):
Patient seated, examiner behind. Palpate the posterior acromion, move one centimeter lateral and inferior to the soft spot. Mark it. Insert and direct the needle upward toward the coracoid.
Critical point about shoulder immobilization: Don’t use slings unless there’s a fracture or dislocation.“If they don’t have a fracture, if they don’t have a dislocation, don’t put them in a sling,” Dr. Duany said. “Just say, ‘Rest your arm, you can do some simple exercises or listen to your body. If it hurts, don’t do that.’”Unnecessary immobilization for two weeks while awaiting physical therapy or ortho consultation can transform simple tendonitis into frozen shoulder, requiring months of treatment.
After six to eight weeks of conservative treatment without improvement, order MRI if X-rays don’t show severe arthritis and provocative tests are positive. Document those tests — positive McMurray, Lachman, empty can or drop arm results get MRIs approved and expedite orthopedic care.
Hot, swollen knee with fever: Consider septic arthritis, though according to Dr. Duany, “gout is actually more common than septic arthritis, and somebody walking into your office is more likely going to be an inflammatory arthritis than an infectious arthritis.”
If comfortable with arthrocentesis, aspirate and send fluid for cell count (infection cutoff: 50,000 white blood cells), Gram stain, culture and crystals. Send to emergency department if infection is suspected.
Suspected fracture: Deformity, major trauma, large effusion, inability to bear weight.
Send directly to orthopedics (skip MRI):
Massive rotator cuff tear: Acute weakness after trauma with positive drop arm test. This is time sensitive.
“I would go straight to ortho,” Dr. Duany said. “Refer to ortho, because if you try to get the MRI, it may delay the care.”
These patients need surgery within one to two weeks to prevent tendon atrophy. Delay can mean the difference between rotator cuff repair and requiring shoulder replacement.
Fracture or dislocation: These are the only indications for sling immobilization. Refer promptly.
Failed six to eight weeks of physical therapy with positive MRI findings. End-stage arthritis unresponsive to injections and activity modification — possible candidates for joint replacement. Frozen shoulder refractory to therapy and injection may benefit from manipulation under anesthesia.
A common diagnostic challenge requires distinguishing primary shoulder pathology from referred cervical pain. Key differentiators:
Numbness or tingling extending into the hand suggests cervical radiculopathy rather than shoulder pathology.
The overhead test helps distinguish: “When you raise your arm up over your head, it’s more painful because you’re impinging the rotator cuff and it’s inflamed,” Dr. Duany said. “But if you have cervical pathology, when you raise your arm up or have them put them on their head, that will feel better. You’re relieving the stress on the nerves.”
When cervical symptoms predominate, obtain cervical spine films before pursuing shoulder workup.