
Shoulder pain is very common. Should we obtain an MRI on everyone with shoulder pain?
The quick and obvious answer is no … but let’s explore why.
- The rotator cuff is the most common source of pain in patients over the age of 30.
- Rotator cuff tears are very common in people over 40.
- The majority of rotator cuff issues are due to degeneration or attrition of the rotator cuff.
- Many degenerative or attritional rotator cuff tears do not need surgery and your pain will improve with physical therapy.
In my everyday life I see two types of people, those with shoulder pain and those who will have have shoulder pain. For most of you, your shoulder pain will subside spontaneously. Many of you will need to see a doctor because your shoulder pain will keep you up at night or make it difficult for you to continue with your daily activities.
What should your doctor do?
Should We MRI All Shoulder Pain?
Today we continue with our Expert Series where 4 Orthopedic Surgery experts in the area of shoulder surgery will continue answering a number of questions about the rotator cuff.
Jeffery Berg, MD: Website, Twitter
As with most diagnosis in medicine, for shoulder problems the patient’s “story” is usually the most important factor in determining the diagnosis. For me, the exam is then next most important. After that the response or failure to treatments (if appropriate for nonoperative care) and finally, imaging studies, including MRIs. In most shoulder problems, MRIs are typically only confirmations of the suspected diagnosis. In younger patients, MRIs are only fair in their ability to accurately identify the common shoulder problems this age group suffers. In older patients, because of the common and often asymptomatic “wear and tear” that is common in these patients, MRI’s often overemphasize the importance of common asymptomatic issues, such as degenerative rotator cuff tears. These are incidentally identified and often do not require any treatment.
As a result, in most cases I try to develop a diagnosis from the history and exam. I use MRIs with shoulder problems in the following situations: 1) Concern for time sensitive or limb or life threatening diagnosis that is unclear from the history and physical exam, 2) Failure to respond to nonoperative treatment and the diagnosis still remains unclear, 3) Need to better define, classify or further assess a known diagnosis, and 3) Preoperative surgical planning (for both me and my patients).
Scott Slattery, MD: Website, Twitter
MRI is currently the best way to image the rotator cuff tendons. Not every shoulder pain patient needs an MRI. A good history and physical exam will usually lead to a reasonable diagnosis without advanced imaging. Deciding to obtain a MRI depends on many factors including the time course and severity of the problem, patient age and activity level, and patient desires. Many painful conditions of the shoulder will respond well to non-surgical treatment. If there is no suspicion that there is a serious underlying problem and/or the problem has been present for a short time, a MRI is usually not necessary. If it seems like there is a serious problem that may require surgery or longstanding pain is continuing and increasing despite good care, a MRI may be appropriate.
Marty Leland, MD: Website, Twitter, Facebook
When I first see a patient over 40 with shoulder pain, my first treatment is anti-inflammatories, physical therapy, and frequently a subacromial steroid injection. I will then see the patients back 6-8 weeks later. If they are much better, there is no need for any further treatment. If they aren’t much better, I get an MRI to evaluate their rotator cuff. I usually do not order an MRI the first time I see them because, even if they do have a small rotator cuff tear, I would like to see if non-operative treatment would help them. If it does, GREAT! They may have avoided a surgery. I only order MRIs if they aren’t getting better. However, if I have a patient with a long history of shoulder pain and weakness and they are very weak on examination, I sometimes do order an MRI after the first office visit.
Derek Ochiai, MD: Website, Twitter
Because a good history and physical examination are very good at picking up shoulder rotator cuff issues, I typically do not initially get an MRI of a shoulder I’m trying to treat non-operatively. I use MRI’s when the diagnosis is in doubt or for pre-surgical planning. If the patient had a violent trauma with a lot of shoulder dysfunction, I might get an MRI in that setting, as acute rotator cuff repair for a complete tear would be reasonable. Likewise, if the patient is an overhead athlete with months of shoulder pain before I see them, I might get an MRI or even an MRI arthrogram (where dye is injected into the joint), to look for a SLAP tear (tear of the labral cartilage), which can occur with internal impingement.
Everyone who presents to an Orthopedist’s office with shoulder pain will not require an MRI. As our experts discussed, we may choose to MRI your shoulder if :
- Your diagnosis is in doubt
- You have not responded to physical therapy and we want to assess the quality of your rotator cuff
- You have suffered a severe injury and present with weakness
Next time you visit an Orthopedist for shoulder pain do not be upset if they do not order an MRI. They are rarely necessary to successfully treat the majority of people with shoulder pain.
Tara
why would a doctor order laserscopic surgery on a shoulder of a 16yr old instead of a MRI? she is a softball player and has been having issues with her shoulder for a while . she went through rehab and that did not fix anything. now the doctor says that they need to go in and see what is wrong because they don’t know. why not just do a MRI first?
Yours sounds like a reasonable plan … It’s often important to know why you are operating on a joint before you start the operation.
Rick
About 20 years ago I was blindsided while refereeing a hockey game and hit the ice full force with my arms straight out in front of me. I finished the game but was hardly able to remove my clothing afterwards due to the pain in both shoulders. Long story short – I saw a doctor, completed a number of weeks of PT with no improvement, had an arthrogram, and saw an orthopedic surgeon who confirmed rotator cuff damage. He said he could only offer 50/50 chance of improvement through surgery since he couldn’t determine from the arthrogram whether the damage was repairable. Since he indicated no long term ill effects from not repairing it – as long as I continued to use the shoulders within my pain tolerance – I elected not to go ahead with surgery due to extensive travel required by my job which would limit PT in recovery.
I’ve lived with various amounts of pain for 20+ years and limited my participation in sports. Two years ago I aggravated the shoulders (hedge trimming, raking leaves) and the pain has now increased to the point where it’s constant, acute and affects my ability to sleep, not to mention doing anything physical.
My question is – given the length of time since the injury and my age (66) would surgery offer me a good chance to at least alleviate the pain if not restore some strength also ?
Thank you.
An old injury doesn’t always mean that it will not respond to treatment now.
For rotator cuff damage that is old you may want to read this post too.
Chris
I’ve had shoulder pain for about 7-8 months now. Last trip to my VA dr I got a cortisone shot. Count tell any difference. The pain is when I raise my arm and starts just under 90 degrees all the way up to 180. The pain is also present below 90 degrees but only while reaching back. I have a follow up appointment in about a week. NSAIDs have also been inneffective. Does this sound more like a tear or an impingement?
Most shoulder surgeons have gotten away from the term impingement. We call this degenerative rotator cuff disease or rotator cuff tendinosis. As such the rotator cuff and surrounding bursa are usually the source of pain… but not because they are being impinged by a bone spur.
A good exam and perhaps an US or MRI can help in determining the status of your rotator cuff. You can talk with your doc to see if they feel that physical therapy would be beneficial.
Good Luck
MaryB
I just had my 3rd MRI/MRA on my left shoulder. Each has shown a torn rotator cuff in the same area. First also showed SLAP tear. I have had surgery on it twice in the last year. Is it possible the tendon is just can’t heal? I am in my early 40s and very active.
Yes… not all cuff tears heal. Some repairs fail due to biology, some fail due to early strengthening, some fail due to early return to full activities, some likely fail due to poor repair technique. As you can see there are many reasons why rotator cuff repairs fail to heal. Figuring out why is important. The results of revision rotator cuff surgery is much worse than the results of the first or the primary repair.
Sharon
I don’t know what’s wrong with my arm it started about 2 months ago I was trying to pick up a door to move and something happened to my right arm, the next day my bicep was black and blue, and ever since that it hurts all the time I can’t pick anything up with my hand without pain going all the way up to my shoulder I can’t sleep for the pain I have to set up , when I try to raise my Are even with it bent it hurts terrible getting no better what should I do?
Time for a Sport Medicine Doc with a shoulder specialty to take a look and see what’s bothering you.
Teal Naiad
I was in a roll-over car accident in 2012 – I was not wearing a seat belt. At first my pain was thought to be from my neck, within months it was concluded my shoulder was also involved. 5 years and several X-rays and 2 MRIs later my diagnosis is still unsure. The pain gets much better if I don’t use my arm – usually during winter months. At todays app. I could not lift my arm to the side above my shoulder. Now they want to do another X-ray. I have a total of over 116 mSv of radiation over my life from thyroid cancer and CT scans among others. Is another X-ray necessary?
Xrays are a very useful screening tool for shoulder injuries.
SMichael
Also Dont believe ever put back into place how would I even know if it was dislocated in the first place?
A good exam by a shoulder doc can usually tell if you had a previous dislocation. The X-ray will also tell if you had a previous dislocation.
Susanna
Hello, Dr Luks,
A month ago tomorrow, I fell flat out on a hard floor and dislocated my right shoulder. I spent a few hours in an ER. and they put it back in place. Since then, I went to 6 sessions of PT. I do exercises at home as well.
I still have a lot of pain in the wee hours at night. There is improvement in my range of motion, maybe 25%.
I feel I need an MRI to assess the damage of the tendons. Any arm movement to the side is still painful .
I do not want surgery if I can avoid it. How many weeks of PT would I need to see bigger results?
Is it a matter of time? And when is it too late to have surgery ?
I’m a 73 year old female, in good shape otherwise. I still ran 9 short footraces in 2016. Never had any major illness. Is it possible to get 90% of range of motion back without surgery?
Thank you for your reply !!
An MRI following a shoulder dislocation in a 73 year old is generally best down earlier rather than later…. that’s because many 60-80 year olds will tear off a large portion of the rotator cuff when the shoulder dislocates.
Good Luck
Eunique
Would a rotator cuff tear cause the back side of my arm to burn?
howard2
hard to say … but it is possible. Burning pain is associated with inflammation and nerve pain— so a good examination can usually tell which one is bothering you.
Eunique
So glad I looked this up! I’m currently seeing an Ortho and I’m also in PT. My Ortho and my therapist have told me I don’t need an MRI because they are both sure I have a tear. My Ortho says it is not significant enough for surgery and most tears can be treated with PT and injections as I also have some other issues with the same arm. I have a lot of friends in the medical field that keep telling me this just isn’t true I should insist on an MRI because my treatment plan may change after imaging. But it seems to me you have the same treatment philosophy. I just needed reassurance that my Dr was recommending the right treatment options and I’m not just suffering through this pain for no reason. I agree that it would seem quite redundant to have imaging taken if it will just confirm some thing he already knows, but when you have a village of medical professionals telling you other wise it makes you second guess your treatment plan.
howard2
Hi …
Your doc is correct … after a certain age, degenerative rotator cuff disease- including the possibility of a small degenerative rotator cuff tear is the most common source of pain. If you have normal strength, then there is no need to rush into an MRI. Even if a small degenerative rotator cuff tear is identified the initial treatment is still PT. I hold off on an MRI until I see how my patients respond to PT. If you complete a course of PT and significant pain persists then an MRI can be performed.
Tori Anne Rouse
Does rotator cuff tears always show up on MRI scans? I had an MRI done, did physical therapy, iced my shoulder, and also took anti flam medication and muscle relaxers and nothing fixed it. I was a CNA and injured my shoulder on the job and my dr told me I that my MRI showed nothing… it’s a year and a half later with nothing getting better…..?
They usually do… Sometimes Radiologists may or may not mention the presence of rotator cuff tendinosis or tendinopathy–which is the most common cause of rotator cuff pain. In addition, some Orthopedists may say “nothing is wrong” to mean that you don’t have a tear… no necessarily focusing on the mention of tendinosis which again is a very common cause of shoulder pain.
Tori Anne Rouse
I just wanted to give an update years later.
I actually ended up having exploratory shoulder surgery because the pain was still not going away 2+ years after my injury, no matter what my dr did. He said that I didn’t have a bicep tear, but something was wrong with my bicep. He did a bicep tenodesis to repair it. It took the pain away in my armpit, but I live with chronic pain and have a hard time sleeping on it or lifting my arm above my head without my arm going numb and hurting. It sucks and I got a 12% disability score.
Caoline mwieria's
Can an MRI tell how old a rotator cuff tear is???
On rare occasions it can tell us if a rotator cuff tear is acute (recent) or chronic (older). But in general, no … it can not give precise information regarding the age of a tear.
Adam
Dr. Luks,
I am 29 years old and had major rotator cuff surgery 9 months ago. Around month 6 of recovery I was moving furniture and had a HUGE increase in pain and symptoms. I continued with my therapy for about two months but had no improvement in symptoms. My doctor ordered an MRI which came back negative. I requested a second opinion and that doctor ordered an MRA which also came back negative. This is great news for me except that I am still having terrible pain. Not just a little soreness or surgical pain but extremely bad pain that renders me inactive. I can’t lift weights, I can’t swim, I can’t do anything except very light rotator cuff exercises which are uncomfortable but bearable. I am a very active person and have played sports my entire life so I am familiar with shoulder tendonitis or tweaks that typically heal within 6 to 8 weeks. This is nothing like that. This pain is identical to the pain I was having before the surgery. My quality of life is very low because I am a very active person but I can’t do anything without pain. I don’t know what else to do. After reading some research it suggests that an MRI/MRA are not extremely sensitive to partial thickness cuff tears, especially retears. I guess my question is when should I or my surgeon consider a scope? What are the odds that both an MRI and an MRA from two different doctors are both negative? Thanks so much Dr. Luks.
Adam
Kristi
, I am having the same problem after surgery. I lifted up something heavy and felt like I tore a muscle or something in my arm. However, nothing is showing up in the test, what were your results?
Jennifer Seate
Good information to review when you have shoulder pain. I’ll definitely pass the information to my clients who think you MUST have an MRI. Thanks!