Red Herrings in your shoulder?

Shoulder MRI showing a full thickness tear of supraspinatus

Shoulder pain is estimated to affect up to approximately 20% of the population right across the lifespan and is thought to have numerous environmental, occupational, psychosocial and individual risk factors. To put it simply, there is rarely a smoking gun!

It is common to have a short bout of episodic pain that resolves on its own or may need some more specific intervention. For some, however, these episodes can be more frequent or even develop into long-term, chronic shoulder pain and dysfunction.

You may have been given a diagnosis of rotator cuff tear, tendinosis, bursitis or something similar which implicates these structures as the source of your pain. Physiotherapists can use a series of “special tests” that aim to further narrow down the likely cause of your symptoms. It is also common to have an ultrasound/X-ray or MRI to assist in diagnosing your injury. These tests and scans, however, are far from perfect and do not offer a “gold standard” in diagnosing shoulder pain. One brief example is a study done this year where the dominant shoulder of 26 asymptomatic (ie. not complaining of any shoulder problems) elite-level volleyball men and women were underwent a clinical assessment and then MRI study. The findings tend to match a growing body of evidence that indicate these studies find injuries warranting surgery in completely pain-free shoulders. The number and severity of such ‘injuries’ found in this study are quite staggering and yet these sportsmen and women were pain free and performing at the peak of their profession.

What does this tell us?

First of all, just because you have a supraspinatus tear or similar, does not mean this is the exact cause for your discomfort. Of course we cannot rule it out either, and correlation between clinical exam and presenting symptoms can useful in gaining a better idea of what is causing your issue and inform your treatment.

Secondly, due to the uncertainty of such special tests and imaging actually able to identify the exact source of pain, surgery may be performed unnecessarily in some patients.

In just about all cases of shoulder pain (excluding significant instability/trauma) operative management should only be considered following a significant trial of conservative treatment.

Scans are likely to show abnormalities that could warrant surgery but are commonly asymptomatic, especially as we age. It is a good idea to have your GP or Physiotherapist go through these findings with you to dispel any concerns you might have.

Our bodies are strong and robust, and despite high levels of repeated stress and trauma, giving way to what could be called ‘kisses of time’ on imaging, are still capable of amazing movements and activities.

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