“Shoulder pain: the importance of getting the correct diagnosis”

Shoulder pain can be debilitating and can leave you feeling miserable, particularly if your sleep has been affected. Most of us will suffer with shoulder pain at some point in our lives, either due to previous injuries or simply due to the “wear and tear” of getting older. Many problems will settle down with rest, painkillers and avoidance of aggravating activities. For the problems that don’t, it is prudent to seek specialist orthopaedic advice at an early stage.

This is because a comprehensive consultation with a shoulder specialist, taking details of your specific history of shoulder problems, combined with a targeted examination and a basic investigation such as an x-ray, is usually enough to reach a diagnosis. Very often I see patients that have had extensive courses of physiotherapy or osteopathy without having had a diagnosis made. This makes it less likely that the treatment offered is going to make them better, as effectively there is no obvious treatment plan or goal. For example, a course of physiotherapy offered to a patient who is in the early stages of a frozen shoulder is not likely to be beneficial for them and may in fact worsen symptoms rather than improve them. Conversely, patients with rotator cuff tendon tears that are not repairable may benefit from targeted physiotherapy to improve the strength of the muscles around the shoulder. Initially this may be painful but usually is less so as the movement of the shoulder improves – without a diagnosis or a treatment plan however the physiotherapy is likely to be judged futile and stopped before it has a chance to work.

I sometimes need an MRI scan to help confirm a diagnosis or to plan surgery but it is important not to rely on a scan too much, as the findings of any scan need to be carefully interpreted in conjunction with the history of the presenting problem as well as examination findings. For example, most patients over the age of 40 will have abnormalities that are apparent on an MRI scan, however these “abnormalities” may not actually be causing any pain or problem at all. A classic example of this is a tear of the labrum, which is the ring of soft cartilage that surrounds the shoulder socket, in a patient who has not sustained any injury to their shoulder. Although the report of the scan usually sounds very dramatic and conjures up fears of significant internal damage, it has to be interpreted in light of clinical findings and, in the absence of any significant trauma to the shoulder, is likely to be an irrelevant finding in this age group. Overreliance on an MRI report may alternatively lead to underdiagnosis of certain conditions such as frozen shoulder, that doesn’t tend to show up well on an MRI scan and is easily diagnosed by a good clinical history and examination, combined with an x-ray to rule out arthritis.

In summary therefore, seeing a shoulder specialist at an early stage to get an accurate diagnosis is important, as this is likely to lead to a better outcome more quickly whilst avoiding treatments, whether non-surgical or surgical, that don’t work. Anxiety over MRI “abnormalities” can be allayed as scan results will be interpreted by a specialist correctly by linking these to the history and examination findings, enabling any irrelevant scan findings to be ruled out.

David Rose

Consultant Orthopaedic Shoulder Surgeon MBBS FRCS (Tr.& Orth.)


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