Shoulder Pain Talk

More Thoughts on Shoulder Imaging

So, when you go into your physician with complaints of longstanding shoulder pain, he may or may not recommend imaging of the shoulder.  The fact of the matter is much of shoulder pain can be diagnosed without any x-rays.  However, there are some times with an initial evaluation that x-rays are needed.

When we think about this imaging, physicians can simply go through the following process.  Plain x-rays – the old fashioned x-rays – will give you good information about the bones.  Is there any arthritis? Is there any bone fractures?  In deed, in one of the fairly common problems called calcific tendonitis, one of the tendons becomes calcified and essentially starts to turn to bone and that can be picked up on x-rays. Certainly cancer, tumors, all these things, if they involve the bone, can be picked up on plain x-rays.  If the tumors are cancer, or not within the bone, then they basically escape the attention of plain films.

Magnetic Residence Imaging, or MRI, is technology that’s been around since the early 80s and it is the best way we have to look at soft tissues.  So that will show any tumors that are not involved in the bone.  They will show more importantly and much, much, much more commonly abnormalities in the tendon, inflammation in the tendon, rupture of the tendon, they will reveal bone fractures that are not seen on plain x-rays and that does happen up to 10% of the time.  They essentially give the most information available cutting without into the shoulder and looking at it.

Ultrasound is a new modality, and it is very useful.  You do need to understand its limitations.  Ultrasound will basically tell you how someone superspinatis tendon is.  Now, keep in mind, the superspinatis tendon is where most of the problems originate with the rotator cuff.  And many times, we will get an ultrasound if we want to find out if its’ worth while to try to treat someone conservatively.  Basically, if a superspinatis tendon is just showing partial tears or inflammation or swelling, then this person will likely get better without any type of surgery.  Even moderate tears can shown on ultrasound, can very frequently be healed without surgery; however, if there is a complete tear in the tendon then there is actually retraction on both sides – so there is basically a separation between the tear – there’s not a great place for physical therapy in my opinion.  So, the ultrasound is a one trick pony, but it can be quite practical and can give us a dream life if we really push the non-surgical rehabilitation aggressively.

Shoulder Pain - How are shoulder problems diagnosed

As with any medical issue, a shoulder problem is generally diagnosed using a three-part process;

Medical history – the patient tells the doctor about any injury or other condition that might be causing the pain.  Time line of the shoulder pain.  Exacerbating and remitting factors...How does the pain get worse?  How does the pain get better?  This will give many clues to the physician about what might be causing this.

Keep in mind the differential diagnosis for shoulder pain is long.  Many different things can cause it.  The second part of the process is physical examination.  The doctor examines the patient to feel for injury and discover the limits of movement, location of pain, extent of joint instability.  Many times this will be enough and medical history and physical exams do a very accurate diagnosis about what exactly is going on with the shoulder. If the doctor still has more questions, the doctor may order more imaging tests to help make a specific diagnosis.

 

A standard x-ray in which low level radiation is passed through the body to produce a picture called a radiograph.  This type of x-ray is useful for diagnosing fractures or other problems with the bones.  Soft tissue such as muscles and tendons do not show up on x-rays.  Ultrasound is a different non-evasive technique in which ultrasound waves can be used to visualize some structures in the shoulder particularly the ones closer to the surface.  Many times the problems with the rotator cuff are due to some of the structures located close to the surface and therefore is very helpful in making this diagnosis.

Finally, a frequently used imaging technique is the magnetic residence imaging (MRI) which is another non-evasive procedure in which a machine with a strong magnet passes a force through the body to produce a series of cross-sectional images of the shoulder.  This allows the doctor to look at the soft tissues and help make a more definitive diagnosis.  Most certainly before a surgery is proposed, an MRI will likely be available for the doctor to review to plan surgery.

Shoulder MRI

Frequently the doctor will get an MRI of the shoulder. MRI is different than x-ray in that it looks at the soft tissue. A great majority of shoulder pain is due to problems with the tendons and the shoulder MRI gives great definition of the tendons as they come out from the medial shoulder and attach to the bones of the upper arm.

Shoulder MRIs are essentially required prior to surgery so that the surgeon can plan the surgery and frequently utilized before physical therapy to help therapists plan an exercise regimen.

MRI of the shoulder is an exam that typically takes about 25 minutes in the scanner.