Year: 2025
Type: article
Abstract: 1. INTRODUCTION Imaging findings should be interpreted within the broader context of an individual's shoulder symptoms (1). While imaging is valuable in identifying specific structural pathologies, findings are often equivocal. Defining what imaging changes constitute "normal", "abnormal", "unrelated", "solely causative" findings, and which are, "contributory", or "associated" with symptoms is a clinical minefield. Although a naive interpretation might equate "normal" with the absence of pathological features (e.g., no rotator cuff tears, calcification, or labral lesions), this is an oversimplification. For example, rotator cuff tendon tears are frequently observed in individuals without symptoms, who function for years at a very high level of performance. Rotator cuff tendon tears increase asymptomatically with increasing age, suggesting, like wrinkles and grey hair, the tears are likely to be a normal non-noxious senescent change (2). Furthermore, individuals may exhibit full mobility, exceptional muscle performance, no symptoms, and above average function despite observable labral tears, tendon irregularities commonly termed tendinosis, or partial/full-thickness rotator cuff tears (3-7). Moreover, non-sinister and non-traumatic soft tissue imaging considered to be abnormal cannot reliably distinguish currently symptomatic shoulders, previously symptomatic, or those that have never been symptomatic, as the prevalence of "abnormal" findings is often similar across these groups (3, 8, 9). It is arguable that many so called "abnormalities" have been labeled as such because they represent deviations in structure from idealized and flawless anatomical drawings. The equivocal association between imaging changes and symptoms has lead researchers and clinicians, to question a biomechanical role in symptom causation and/or perpetuation. This is evident in the arguments such as nociception is not needed to experience pain (10), and that pain should be considered a perception and not a sensation (11). These arguments, commonplace in pain science, are not supported by definitive research and should still be regarding as hypotheses and not "fait accompli". Without doubt, psychosocial factors and the social determinants of health play a seismic role in the experience, perpetuation, and prognosis of symptoms for those living with shoulder pain (12, 13). However, arguments have been made to reframe the relevance of 'bio' in shoulder symptoms, and recently a strong case has been made to consider bio-chemical factors in the development and perpetuation of rotator cuff related shoulder pain (14). The appropriate utilization and necessity of shoulder imaging is also equivocal. Guidelines offer inconsistent recommendations and conflicting advice concerning the prescription of radiographs for diagnosing rotator cuff tendinopathy, as some guidelines recommend radiographs during the initial evaluation (e.g., routinely), although others suggest that radiographs might be considered, especially when conservative treatment fails (15). Notably, one high-quality guideline did not recommend radiographs for the initial management (15). Lastly, International Consensus suggests using certain dynamic imaging techniques as complementary to medical history and physical examination for the clinical assessment of dysfunctional disorders (e.g., subluxation, instability). This approach could aid clinicians in perceiving "functional" disorders rather than solely anatomical or structural injuries (16). As a consequence of this ambiguity, a significant number of clinicians were responsible for referrals for "low-value" imaging, especially for those without a traumatic onset (17). To promote consideration for the role of "bio" in shoulder symptoms and encourage debate among clinicians and researchers, this opinion paper aims to stimulate discussion on the value of imaging in management of musculoskeletal shoulder pain. We sought to capture diverse perspectives from various health disciplines by incorporating input from clinicians, researchers, educators, physiotherapists, physicians, and nurses working within the musculoskeletal field, aimed at providing a comprehensive perspective to our manuscript. 2. PROS AND CONS OF IMAGING USE IN SHOULDER PAIN MANAGEMENT Although the judicious requests of imaging may improve clinician understanding of a specific clinical scenario, between 20–50% of imaging requests are inappropriate or of "low-value" (e.g., a service offering no or minimal benefit to patients). Primum non nocere (first, do no harm) is a core principal in healthcare practice. Unnecessary imaging has the potential to cause harm (e.g. unnecessary risk due to exposure to ionizing radiation) (18), prolong waiting times, and further negatively impact of spiraling healthcare costs (17). Conversely, strategies aimed at reducing low-value imaging have the potential to decrease costs by as much as 95% without compromising patient well-being (17). How patients interpret the imaging report findings will influence their beliefs about appropriate management, (e.g. "I have a tear, I need surgery") (19). When writing an imaging report, pathoanatomical labelling without reference to the incidence and prevalence of findings in people without symptoms could lead to "medical overuse" as unnecessary injections, surgical and nonsurgical procedures (20), as well as healthcare-seeking behavior reinforcing maladaptive beliefs about damage (21). A further concern in the interpretation of shoulder imaging is the observed fair to moderate inter-rater agreement among different examiners when reporting on identical scans (9, 22), a factor that is also influenced by the experience of the individual professional and which can potentially result in patient disorientation, unhelpful guidance, and unwarranted subsequent investigations (23). Studies investigating this issue, question the clinical utility of routine imaging for treatment planning, given the high prevalence of anatomical variations in asymptomatic shoulders (1, 8, 9, 24). Indeed, while imaging may identify tissue pathology, it often cannot reliably determine the clinical significance of these findings or their correlation with specific symptoms. For instance, routine plain radiographs in individuals with atraumatic shoulder pain altered the diagnosis based on medical history and physical examination in fewer than 15% of cases, and clinical management was modified in only 1.7% of cases (25). Furthermore, in individuals with frozen shoulder, additional pathologies were identified via magnetic resonance imaging in 22% of subjects. However, a modification in the treatment plan based on these findings was observed in only 2.7% of cases, and 37 resonance scans were required to identify one patient with frozen shoulder necessitating surgery due to the additional imaging findings (26). In conclusion, acceptance of imaging findings (i) without defining what abnormal is based upon and (ii) without stating the prevalence of such findings in people without symptoms, may lead to over medicalization and detrimentally impact on healthcare sustainability. Getting the balance right The thoughtful application of imaging strategies may confer several advantages. Firstly, imaging may identify relevant structural pathologies when serious pathology is a primary concern (27). In complex, traumatic, or suspicious cases, where differential diagnosis is challenging due to the overlap of clinical signs and symptoms, the selection of the appropriate imaging modality may help prevent delays in management (28). Moreover, imaging may corroborate structural healing following surgical intervention. For instance, in rotator cuff repair, an ultrasound scan or magnetic resonance imaging can confirm the secure placement of bone anchors, demonstrating the technical success of the surgery. Although importantly, from a clinical standpoint, tendon to tendon, and tendon to bone healing is not a prerequisite for a reduction in pain and improvement in function after repair (29, 30). When indicated based on a suspicion of clinically significant structural failure, imaging will be invaluable for a detailed assessment of tissue biology (e.g., a bony Bankart lesion following trauma-related anterior shoulder instability). This information will guide targeted and shared treatment decisions and facilitate specialist involvement (e.g., surgical consultation) as necessary, promoting a positive multidisciplinary approach involving specialists capable of accurate, evidence-based interpretation of structural details. Lastly, in cases where non-surgical management does not result in the expected clinical improvement, the contribution of traumatically and non-traumatically acquired structural variations warrants evaluation, facilitated by the wise selection of imaging for changing the path of care (27). In Table 1, we presented scenarios taken from everyday clinical practice to stimulate discussion on pro-and cons-for imaging use in shoulder pain management, while Figure 1 (Supplementary material), details a SWOT -strength, weaknesses, opportunities, and threat-analysis for the use of imaging in shoulder pain management. Lastly, we have included a clinical decision-making diagram (Figure 2, Supplementary Material) to illustrate the authors' proposed method for integrating clinical and imaging findings. This diagram is designed to simplify the decision-making process for determining when imaging is necessary, unnecessary, or a borderline case. 3. IMPLICATIONS Prior to, or during attendance at out-patient shoulder orthopedic clinics routine imaging (usually radiographs) is common practice. This may help identify rare conditions requiring urgent management, such as osteosarcomas. However, in-depth interview practice and appropriate safety netting would reduce the need for blanket imaging and lessen the potential harms associated with being informed of tendon and/or bone changes that may, and equally may not be associated with symptoms and in the main will respond equally well to non-surgical management. "Low-value" imaging equates to billions of dollars of wasted resources. For example, within magnetic resonance imaging, a primary cohort receiving imaging referrals discordant with guidelines included orthopedic patients and patients referred by general practitioners (17, 31). Additionally, atraumatic pain was identified as a specific clinical condition where the use of "low-value" imaging was particularly evident (17). Measures for reducing "low-value" imaging and to promote reasonable use and recommendation of it are needed at all levels of healthcare, for promoting interprofessional collaboration and networking, thereby improving patient care and perceived support by the patient. Clinical guidelines recommend judicious use of imaging in people with shoulder pain, discouraging routine imaging, but fully utilize their use in probable red flag presentations (27, 32). Imaging should also be considered in non-improving (possibly at 12 weeks), or earlier, with worsening symptoms (27, 32). The appropriate utilization of imaging for a comprehensive understanding of clinical scenarios holds significant implications for both clinical practice and research. Clinicians (e.g., physicians, chiropractors, physiotherapists) bear the responsibility to justify the need to image and if a decision to image is made, determine the appropriate timing and type of imaging studies. This must be done within a shared decision making framework, and to recognize when multidisciplinary consultation is necessary to address patient needs effectively (33). Shared decision making requires consideration of the benefits and potential harms of imaging. It needs to be framed within comprehensive patient education, encompassing the current clinical status and patient wishes for management. For example, in the absence of red flag concerns is imaging necessary for a patient who wishes to focus on non-invasive, non-surgical management (34)? This opinion paper aims to stimulate a mature, balanced discourse that empowers less experienced clinicians to make informed decisions with individual patients, considering all pertinent factors contributing to their well-being. Within a proper application of the bio-psycho-social model of care, biological variables must be acknowledged, and in-depth analysis through imaging modalities can serve as a valuable strategy. As showed in the six clinical cases in Table 1, people presenting with painful shoulder conditions, particularly when specific anamnesis and predisposing factors were present, imaging may: • Confirm the presence of structural abnormalities requiring multidisciplinary consultation (e.g., expert opinion(s)). • Guide clinicians towards targeted interventions addressing specific structural pathologies, thereby enhancing treatment efficacy (e.g., calcific tendinopathy). • Prevent adverse outcomes resulting from misdiagnosed conditions (e.g., instability with rotator cuff tear). • Facilitate accurate differential diagnosis, mitigating the risk of overlooking clinically significant comorbidities (e.g. frozen shoulder). 4. CONCLUSION Clinical practice frequently lacks balance and frequently is conducted at the ends of a spectrum. With one end being rigid reliance on structural imaging and the other its rejection in favor of a psychosocial narrative. Yet clinical reality is rarely binary, and practicing at the end of any spectrum, as is in most situations in life, leads to cognitive distortion, and blind adherence to one belief over another. Recent medical examples include the discourse on vaccination, and in physiotherapy, the -often-toxic debate relating to touch therapy. The Latin phrase, in medias res (the solution lies in the middle) is very apt. To promote a judicious, resourceful, and evidence-based utilization of imaging, research should emphasize a comprehensive bio-psycho-social care pathway. Within this framework, all relevant domains should be engaged and weighted according to the specific clinical context. Educational curricula for all health professions should incorporate formative modules designed to enhance expertise in imaging strategies, including their clinical applicability and utility, strengths and limitations, and potential benefits and drawbacks. Moreover, receiving individualized written audit and feedback on imaging request rates —including the benefits of addressing imaging overuse, links to educational resources, and guidance on limiting imaging requests— could significantly decreased overall rate of musculoskeletal imaging requests (35-37), and could be a widely strategy for enhancing professional practice. A balanced, context-driven use of imaging, grounded in clinical reasoning and embedded in a biopsychosocial model, can enhance diagnosis, inform treatment, and support shared decision-making. Imaging is a valuable tool when used wisely: the question is not whether to use it, but when, why, and for whom. Table 1. Clinical practice scenarios to stimulate discussion on pro-and cons-for imaging use in shoulder pain management CLINICAL SCENARIO CASE DISCUSSION Suspected red flag conditions A presented via with atraumatic right shoulder pain. The patient right pain the of the and of shoulder pain with also a of Notably, pain when on right in or sensation were and the clinical shoulder examination was Clinical The initial to guide their decision to and for further imaging or or the patient for medical evaluation if the are to fails the of The patient with shoulder pain, a and pain that with but is not during a physical shoulder The pain is by on the The of the presence of a and pain that from the shoulder red for a cause These signs suggest a potential issue, such as or a This suspicion an for medical In shoulder pain can often be referred from various and pathologies, a shoulder Imaging is the appropriate initial imaging modality to This imaging and are for the patient a and accurate diagnosis, to appropriate medical treatment rather than painful shoulder A presented to a practice with shoulder pain. a from a of one one did not care as the pain was not the pain has and is at Clinical The patient has a history of and over the of a their shoulder pain and of function have with pain. A significant risk factor is their history of which The patient also with and which could a shoulder The of pain and the risk factor of use a strong suspicion for a as an or a shoulder which particularly were as The patient has a history of the of years and at with during symptom can be of that these injuries specific management and can with a in diagnosis, imaging is over conservative Imaging Imaging is for a definitive diagnosis, and is when the bone of the or concerns about bone It is also necessary when the patient pain that decrease after or when a is evident in the of the shoulder and Notably, some like an might not cause pain and could be not In this scenario, imaging to confirm a or identify a shoulder when clinical examination is not In while observable signs like a a of the anterior shoulder and with anterior and shoulder pain and and (possibly due to an associated lesion can these signs might be in In this and are for to the and identify this pathology, as it often requires a different of treatment (e.g., or to Rotator cuff calcific A presented to a practice reporting a onset of and pain for in shoulder, experienced the and an to The patient significant pain medical history included and but no history of Clinical the clinical features during the medical history reporting with a history of presenting with shoulder pain and cuff calcific should be considered The presence of calcific with symptoms, as only about of individuals with report shoulder pain and the of is often to symptom Clinical examination may not the imaging is necessary to confirm the diagnosis and guide a treatment plan Imaging with is the imaging modality of It can confirm the presence of calcification, determine its and and help if it is in an painful Moreover, a of ultrasound and can help determine if is the of pain, significantly management This information is for management, as it for specific interventions like or which are for this The resulting treatment plan can be to the potentially providing and outcomes than general conservative care Moreover, calcific can in various anatomical they could diverse conservative or on the specific of calcific a to the integrating both clinical and findings, is for care and enhancing the of that the between and clinical outcomes or treatment and it is still a A presented to a practice following of for a traumatic reduction via and after of The medical history included a history of and a history of in a rotator cuff repair was for the and Clinical In patients over who have experienced a traumatic shoulder a rotator cuff is a concern that requires pain and can be significant as they may potentially to a predisposing such as history and and should also suspicion and further The main decision is whether to consider imaging when clinical pain or prevent a or when predisposing risk factors are A diagnosis can outcomes and lead to rotator cuff evidence-based practice a approach to in these specific patient Imaging Imaging should be considered a rotator cuff is particularly when clinical are A comprehensive understanding of the clinical through imaging, is for a or a for a and management which can prevent the from worsening and significantly improve shoulder A presented with a history of and shoulder pain, to The patient and an to Clinical to consider the differential diagnosis of frozen shoulder, as several pathologies can like of the and can with similar symptoms and be reliably through a medical history or physical A predisposing such as a history of or or of was also with an due to pain. medical history included a pathology and a history of years can be risk factors for both frozen shoulder and these other serious In this and were predisposing factors for frozen shoulder development but and are also risk factors for Moreover, the history of warrants consideration The main decision when to imaging. While some support routine imaging for unnecessary without a history of a serious others especially when predisposing risk factors are The is to confirm a diagnosis of frozen shoulder or to identify a potentially or condition that requires and often management. should and the diagnosis if a patient improve with treatment or if their symptoms Imaging Imaging is a tool in these a is it could be is and appropriate treatment can significantly improve the of A suggests that if a patient with a frozen shoulder respond to initial and an imaging should be to other pathologies Rotator shoulder pain A presented at a with a history of shoulder pain on the the such in The patient no history of The individual does not or in has a high Recent medical history included a to a to This and Clinical The patient with shoulder pain but without a history of or findings include a high a history of overuse, minimal in of a painful and with factors increase the suspicion of rotator shoulder pain the history and symptoms, imaging is not the focus should be on a of conservative for imaging could be Imaging findings have a association with symptom perception and are to the treatment Moreover, a interpretation of imaging by regarding the prevalence and incidence of tendon structural abnormalities in asymptomatic individuals could be to in and adherence to Additionally, this could for increase "medical overuse" and Clinical examination a painful of during shoulder a full of was Furthermore, assessment of and while at of on the maladaptive beliefs imaging has not value (12, 13). Imaging A is the primary management strategy. This patient on their and (e.g., improving and physical through and incorporating change strategies the educational is frequently and by individuals with rotator shoulder pain and represent a of interventions for enhancing clinical outcomes in shoulder tendinopathy, Imaging should be for cases where the symptoms improve with conservative care or if an worsening of symptoms within a reasonable (27, 32). This approach "medical maladaptive beliefs about the and patient in a treatment
Authors: Fabrizio Brindisino, Paul Salamh, Chad Cook, Jeremy Lewis, Alvisa Palese, Germano Guerra, Jacopo Bonavita, Giacomo Rossettini
Language: English
Subfield: Surgery
Field: Medicine
Domain: Health Sciences
Open Access status: gold
Estimated APC paid: $2,353
OpenAlex ID: W4413803656