Questions over the necessity of early shoulder scans

Monash University researchers reviewed existing evidence and concluded most shoulder problems get better with self-management, education and time, challenging widespread clinical reliance on early imaging and surgical interventions.

The review, published in JAMA Internal Medicine, provides general practitioners and physiotherapists with an updated roadmap for managing shoulder pain.

It suggests that simple supportive care delivers better patient outcomes in most cases, rather than unnecessary scans and invasive procedures.

Shoulder pain affects nearly one in six adults each year, making it the third most common musculoskeletal complaint in primary care, behind back and knee conditions.

The review emphasised that for most of these patients, routine scans such as X-rays, ultrasounds or MRIs are not recommended because what appears on a scan often did not explain a person’s pain.

The researchers advise clinicians to instead focus on understanding a patient’s symptoms and history, conducting a physical examination, providing reassurance about their expected recovery, and recommending activity modifications, symptom relief or a wait-and-see approach where appropriate.

Lead author Dr Romi Haas said initial assessments should focus on ruling out serious underlying causes, such as infections, tumours or broken bones, and distinguishing localised shoulder pain from referred pain, such as pain originating from the neck or heart.

“The traditional approach has been to look for a structural flaw by scanning the shoulder, assuming that if you can identify the source of the pain, you can fix it,” she said.

“However, global evidence shows these findings are often just normal signs of ageing, akin to grey hair or wrinkles. Unwarranted imaging can wrongly attribute a person’s pain to these normal age-related changes, causing undue worry, overdiagnosis and treatments they don’t need. Importantly, early scans don’t improve long-term recovery.”

Subacromial pain is the most common presentation of shoulder pain, usually felt around the top and outside of the shoulder, and can worsen when lifting or reaching with the arm, or when sleeping on that side.

“Structural labels like 'bursitis' or 'tendon tears' make people think their shoulder is damaged and needs fixing,” Dr Haas said.

“Shifting to location-based labels, such as ‘subacromial pain’, helps reassure patients that it’s safe to keep moving while they manage their symptoms and recover.”

Co-author Dr Thomas Ibounig, a shoulder and elbow surgeon at Helsinki University Hospital in Finland, said the evidence was just as relevant for surgeons as it was for other clinicians.

“High-quality evidence has found that a common shoulder operation, which removes bone and tissue to create more space for the tendons, provides no meaningful benefit over a dummy procedure, where incisions are still cut into a patient, but nothing has been repaired,” Dr Ibounig said.

“It's a reminder that pain isn't always caused by an anatomical or structural problem we can simply fix with surgery. This guidance helps clinicians explain that clearly, so patients aren't unnecessarily worried or pushed toward treatments they don't need.”

Dr Haas said the same principle applies to corticosteroid injections.

“They can provide short-term pain relief, but they don’t routinely need to be guided by imaging. Evidence shows an injection given by a doctor using the patient’s physical anatomy as a guide works just as well, without the additional cost or inconvenience of imaging," she said.