ED: Advanced imaging, particularly MRI, has led to greater accuracy in diagnosing the painful shoulder. However, too much information can create its own problems.

By Dr Jonathan Spencer, Orthopaedic Surgeon, Hollywood Hospital

Shoulder pain is very common in an ageing population. Until fairly recently diagnosis relied on history, examination and plain x-rays, followed by either operative or non-operative treatment. This worked particularly well for fractures, advanced osteoarthritis, rotator cuff arthropathy and massive cuff tear. These conditions generally had signs on the plain films. A normal x-ray resulted in a period of simple treatment or procrastination to see if symptoms would ease.

Today, the mainstay for investigation is USS and MRI.

MRI has had the greatest impact, providing very detailed imaging of shoulder soft tissue pathology, which in a proportion of cases has been of great benefit to the treating clinician. However, the excessive information presented can at times result in difficult interpretation over what is relevant and what is not.

The words ‘tear’ and ‘bursitis’ can create much anxiety in both the patient (and doctor) and can result in over treatment. Apparently significant pathology in one group of patients may be completely irrelevant in another.

For example, a full thickness rotator cuff tear in a 40-year-old is a severe debilitating pathology requiring expedient surgery. The same condition in an 85-year-old can be part of normal ageing and it may become entirely asymptomatic, with surgery not required.

Equally, a doctor may be led down the wrong path by a scan that reports a ‘partial thickness tear’ and ‘bursitis’ in a 45-year-old female who actually has a frozen shoulder.

More accessible MRI results in patients getting scans quickly, which adds to Medicare and patient expense and may not benefit their management greatly. A plain x-ray and USS remains the first line investigation.

Many patients with shoulder pain recover over time, often with simple treatment, and for those who do not settle, an MRI may be indicated.

However impressive the imaging is, we must remember that it forms only a part of the ‘weight of evidence’ required to make a correct diagnosis, and commence the correct treatment.

The diagnosis is still made with a history and examination, followed by appropriate investigation. We need to interpret scan reports with care and be aware that the reported pathology may not be the cause of the patient’s symptoms.

Key Messages

  • The history and examination should not be underestimated in guiding patient treatment.
  • Plain x-ray is always the first line investigation.
  • Imaging reports should be interpreted cautiously and in the each patient’s context.

Further reading:

Prevalence of abnormalities on shoulder MRI in symptomatic and asymptomatic older adults. Gill TK, et al. Int J Rheum Dis 2014.

Initial assessment of the injured shoulder. Shane Brun, AFP, Vol 41, No.4, April 2012, 217-20,

www.racgp.org.au/afp/2012/april/initial-assessment-of-the-injured-shoulder/

Author competing interests: nil relevant disclosures. Questions? Contact the editor.

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