In the last blog we began looking at how to decide if surgery or physiotherapy would be the best option and were using a case study of a patient in his mid 30s with shoulder pain as an example. We tried to answer the simple question that patients often have: “What is wrong with my shoulder?” and found that it is very difficult to be certain of the exact problem and that usually the best approach is to work on the weaknesses and limitations identified in the assessment.

In this blog we will try and look at when it might be worth considering getting a scan and how useful that scan might be. So, in our example our sporty mid 30s male has been following a programme of rehab, strengthening and some stretches aimed at strengthening his shoulder and allowing him to return to the gym and lift heavy weights. He has also been doing some weights in the gym but only at an easy level. It is now 4 weeks since our initial consultation and this is our third session in total. Overall he describes things improving, he is getting less pain, it is less intense and less sore in general. However he is still concerned that it is now 3 months since it began and he still can’t do what he used to. He is now asking about having a scan and will that show what he has done? These are perfectly understandable questions in anyone with a problem that has lasted so long but as we will see a scan may be able to show the inside of the shoulder and find problems but whether these problems are the things causing pain is another matter!!

So, first question to answer is: Does our patient need a scan? Well he has only been following a proper rehab regime for 4 weeks and things are improving. So the easy answer (from my physio perspective) is no! Understandably he wants things to improve more quickly but unfortunately tendons and shoulders tend to have lengthy recovery time periods that most patients really struggle to accept. Certainly 4 weeks is way too short a time in this example to consider a scan. Also, it is important to understand that the only reason to have a scan apart from ruling out sinister pathologies would be to change treatment and in this case he is doing well and just needs to be more patient. Another important point and one that is hard to get to grips with is that an MRI (the usual scan method) may show lots of problems such as a SLAP tear, bursal thickening, swelling, rotator cuff tears and arthritis but deciding if any of these are causing actual problems is by no means easy! But… if there is an injury identified on a scan, surely that will be the source of the problem and surgery should fix it!? Well, not exactly no! There is a large amount of evidence now that suggests that having an issue identified on a scan is not a predictor of pain and in fact many people with absolutely no shoulder pain at all when scanned will have large problems identified by the scan! For example this study here: https://www.ncbi.nlm.nih.gov/pubmed/?term=tempelhof+1999 looked at approximately 400 people with no shoulder pain and found that approximately 23% of people over the age of 50 had rotator cuff tears and that over the age of 80 this was over 50%! Now, obviously these are older than our patient but it does go to show that possibly rotator cuff tears are a natural part of aging and they may not be directly responsible for shoulder pain. An interesting study here https://www.ncbi.nlm.nih.gov/pubmed/12975193 showed that 40% of elite throwing athletes had rotator cuff tears with nil symptoms! To read in more detail about this I would recommend reading this blog by shoulder specialist Adam Meakin https://thesports.physio/2013/04/16/rotator-cuff-tears-cables-and-crescents/

So this is all fairly depressing, the evidence seems to suggest that scans are of no use whatsoever!? Well not exactly… I think the point to take away from this is that scans in isolation can not be used to determine whether someone should have surgery or what exactly the problem in a shoulder is. Scans should only be used in conjunction with information from the patient and the results of an assessment and even then one needs to take into account that many of the anomalies present on scans may have been there for many years especially in an older patient.

In our example, my opinion is that the evidence suggests that we need to wait longer before our patient has a scan as the evidence from the scan may not be as reliable as we once thought and our patient only really needs to consider having a scan if rehab is not helping.

In the next blog we will try and answer the thorny question of when should you consider shoulder surgery?