By Dr. David Bokermann, PT, DPT, C-PS
Shoulder pain is incredibly common. We see it on a daily basis in our PT clinic. The annual prevalence of a person experiencing shoulder pain lasting 1 month is between 18-26%, which means between 1 in nearly 4 people will deal with shoulder pain at least 1 time per year.
In order to effectively treat so many people with shoulder pain, we need to be able to diagnose the problem, create a clear path for treatment, and establish steps for the resolution of pain. We do this on a daily basis without the use of X-rays or MRIs. Although we don’t utilize medical imaging in creating our clinical diagnosis, I will explain to you why 2 other aspects of the evaluation are more important than an expensive image. Those 2 aspects are the subjective history and physical examination.
When a patient presents to the clinic, the first thing we do is listen and let the patient explain their story- we are looking for key features which help to explain common causes of pain. Subjective history includes:
- How the pain began- was it traumatic or did it start gradually over time?
- Is the pain constant, getting worse, or slowly improving?
- When is the pain present? Does the arm hurt mainly at night?
- Is there anything that the patient does to make the shoulder pain better?
- How severe is the pain during common tasks such as dressing, reaching, driving?
Physical examination includes:
- Assessment of active motion- how far the shoulder moves in each direction?
- Assessment of muscle strength- applying a consistent force to each muscle group to gauge its ability to contract under tension.
- Assessment of joint mobility- Passively moving the joint in different planes to gauge the end feel of the joint.
- Assessment of the nervous system- is there full sensation, are the nerves sending signals correctly?
The information gathered from the subjective history and physical examination will create a clear picture if an MRI is warranted or if treatment can begin in the clinic.
Let’s break down 2 patient examples of how a physical therapist would use their skills to determine if an MRI would be necessary.
Patient 1– Injured shoulder 1 week ago, falling on an outstretched arm while snowboarding. Felt immediate sharp pain and a feeling of shifting in his shoulder. His pain is the same, hurts a little at rest but is 8/10 when he tries to move his arm, get dressed or sleep on his shoulder. It hurts at night. If he takes ibuprofen his pain only gets a little better and he needs help getting his shirt on. Physical exam: Can only lift his arm to shoulder height with a lot of effort, he is unable to hold his arm up against very light pressure in any position, his muscles are so guarded his joint mobility can not be assessed but reports no numbness or tingling down his arm.
Patient 2: Shoulder pain began 3 months ago without a known cause, but started to hurt when bench pressing and military press. He denies any history of trauma. Pain is not present at rest but only hurts during reaching in the backseat of his car or at the gym. His pain is the same but not constant. If he avoids bench press and military press his shoulder does not bother him in the gym. Physically he has limited active motion overhead and in rotational motions. His strength is appropriate in all motions but has pain and a little weakness when resisting motion with arm away from body. His joint mobility is limited in rotation in 1 direction and has tenderness along his rotator cuff muscle. He occasionally has numbness in the outside of his arm after sleeping on his side.
Hopefully reading through the subjective history and physical examination of 2 different patients, you can see that these patients’ recommendations may be a little different.
I would recommend an MRI for patient 1, but I would not recommend an MRI for patient 2.
For patient 1– his injury was traumatic- there is a known cause for a potential significant tissue injury due to the force from a fall. His functioning is very poor with inability to lift arm, his strength indicates a potential significant injury to his muscle system, and his pain is not improving whatsoever even after 7 days.
For patient 2– there was no injury that caused the pain so the likelihood of significant tissue injury is very low, his biggest limitation is weakness caused by pain which is typically related to mechanical issues versus structural issues. His functioning is appropriate, his pain is not constant, and it does not limit him outside of the gym.
As you can see, there is a lot of information needed to determine if an MRI is appropriate and warranted for each individual case. Seeing a skilled physical therapist for your shoulder pain is the Best First Step to set you on a path to recovery. We will use your subjective reports and physical exam to create a clear diagnosis for you, as well as a treatment plan to resolve the pain and get back to the things that matter most.
Learn more about our unique approach to resolving shoulder pain: https://www.recoverrxpt.com/shoulder-pain
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