GPs, give imaging the cold shoulder: Why routine scans aren't always the answer for shoulder pain
Shoulder pain is a common complaint, but it's often short-lived and manageable with simple supportive care. That's the message from a recent systematic review of 61 studies, published in JAMA Internal Medicine, which found that routine imaging is rarely necessary for new shoulder pain. This is a significant finding, as it challenges the conventional wisdom that imaging is always the best first step in diagnosing shoulder pain.
The review, led by Dr. Romi Haas, a research fellow at Monash University, highlights the importance of a pragmatic approach to shoulder pain management. Dr. Haas emphasizes that subacromial pain, the most common presentation of shoulder pain, can usually be managed successfully by a general practitioner (GP). Initial assessments should focus on ruling out serious underlying causes, such as infections, tumors, broken bones, or referred pain.
One of the key insights from the review is the need to move away from structural terminology in diagnosis. Terms like bursitis, tendinopathy, a tear, or impingement often imply a distinct structural cause that requires fixing, even when it may not be the source of the pain. Instead, Dr. Haas suggests using the label 'subacromial pain' to describe anterolateral shoulder pain, typically affecting active movement (especially overhead) without passive movement.
This approach has several benefits. Firstly, it helps reassure patients that it is safe to continue modified activity and encourages appropriate symptom relief and wait-and-see approaches where appropriate. Secondly, it reduces the reliance on imaging, which can be costly and may miss other areas or suggest false causes, including age-related changes mistaken for the source of the pain.
Dr. Haas also highlights the limitations of imaging in diagnosing pain in other areas of the body. For example, pain in the neck, heart, or lungs can usually be screened for using a thorough patient history and clinical exam, prompting further targeted investigation or urgent referral, rather than relying on scans.
The review also found that corticosteroid injections may provide short-term pain relief for patients with moderate to severe pain when guided by their anatomical landmarks. However, surgical treatment showed no important benefit for people with subacromial pain who did not have a full-thickness rotator cuff tear. Even for full-thickness tears, the evidence of surgery's effectiveness was limited due to a lack of placebo-controlled RCTs with long-term follow-up.
The findings of the review are supported by another study co-authored by Professor Rachelle Buchbinder, a rheumatologist and clinical epidemiologist from Monash University. This study found that almost every adult over 40 has rotator cuff abnormalities on MRI, irrespective of whether they had shoulder pain. This highlights the widespread prevalence of rotator cuff issues and the need for a more nuanced approach to diagnosis and management.
The recommendations from the review are in line with the advice provided by the Royal Australian College of General Practitioners (RACGP) for the better part of a decade. Most existing guidelines recommend six weeks of rehabilitation before proceeding to imaging if symptoms persist. However, Dr. Joshua Hatch, Chair of the RACGP musculoskeletal, sport and exercise medicine special interest group, cautions that patients experiencing pain at rest, pain that doesn't respond to simple pain relief, or any pain that appears disproportionate to the injury should be referred for further investigation.
In conclusion, the review and its supporting studies emphasize the importance of a pragmatic approach to shoulder pain management. By focusing on a thorough history and clinical exam, and using appropriate labels for shoulder pain, GPs can provide effective and safe care for their patients, reducing the reliance on unnecessary imaging and invasive procedures.
