Diagnostic Imaging Pathways - Chronic Shoulder Pain
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Population Covered By The Guidance
This pathway provides guidance on the imaging of adult patients with subacute or chronic shoulder pain without a definite precipitating event, or patients with persistent shoulder pain following an injury despite conservative management.
Date reviewed: November 2018
Date of next review: November 2021
Published: March 2019
Quick User Guide
Move the mouse cursor over the PINK text boxes inside the flow chart to bring up a pop up box with salient points.
Clicking on the PINK text box will bring up the full text.
The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.
| SYMBOL | RRL | EFFECTIVE DOSE RANGE |
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None | 0 |
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Minimal | < 1 millisieverts |
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Low | 1-5 mSv |
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Medium | 5-10 mSv |
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High | >10 mSv |
Images
Image GalleryNote: These images open in a new page | ||
|---|---|---|
| 1 |  |
Anterior Shoulder Dislocation Image 1 (Plain Radiograph): Anterior shoulder dislocation showing anterior, medially and inferiorly displaced humeral head. |
| 2 |  |
Supraspinatus Tendon Tear Image 2 (Ultrasound): Full thickness supraspinatus tendon tear of the left shoulder (arrow). |
| 3 |
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Glenoid Labral Tear Image 3 (MR Arthrogram): Axial fat-saturated proton density image of shoulder showing anterior labral tear. |
Teaching Points
Teaching Points
- A number of shoulder conditions are diagnosed clinically and managed conservatively such as osteoarthritis and frozen shoulder (adhesive capsulitis). The role of imaging is to rule out other causes that are amenable to surgical treatment such as a complete thickness rotator cuff tear. Imaging may be undertaken if there is no improvement after initial conservative treatment
- Although radiographs are generally of little use in atraumatic shoulder pain, they can be useful to screen for other potentially serious causes if the original diagnosis is in doubt. Plain radiography can be used to rule out osseous causes of pain including occult fracture, dislocation, malignancy and avascular necrosis of the femoral head, as well as calcific tendonitis
- Further imaging studies should only be considered if they are likely to provide additional clinical information which could potentially alter treatment
- MRI and ultrasound are useful investigations to evaluate soft tissue structures
- Ultrasound is preferable if the question is only to evaluate for a rotator cuff tear as it is cheaper, more acceptable, has equivalent accuracy and has no contraindications
- MRI is preferred for evaluating labral abnormalities and nerves
- MR arthography can be useful as a problem solving tool if MRI does not identify the cause of symptoms
xray
Plain Radiography
- Where imaging is indicated, many authors agree that plain radiographs should be the initial investigation 1-6
- However, evidence suggests that plain radiography rarely changes management in atraumatic shoulder pain 7
- The advantage of radiography is that it is a safe, fast and inexpensive imaging modality that can demonstrate or rule out a number of conditions affecting the shoulder 1
- Radiographs are good for detecting several causes of shoulder pain that are not well demonstrated on ultrasound, including fractures, dislocations, calcific tendonitis, avascular necrosis, osteoarthritis, inflammatory arthropathies and bone tumours 1
- In patients with suspected soft tissue pathology who do not improve after conservative treatment, radiographs can be useful to assess for missed diagnoses, although the yield is generally low
- Different situations require different views (AP, lateral or axillary views). Shoulder trauma protocols should have ≥3 views, 2 of which are orthogonal 8
us
Ultrasonography
- MRI and ultrasound (US) are both useful investigations to assess impingement or rotator cuff tears 1,2
- US is preferable if the question is only to evaluate for a rotator cuff tear as it is cheaper, more acceptable, has equivalent accuracy and has no contraindications 4,9,10
- US has high accuracy for the detection and staging of full-thickness rotator cuff tears, but is less sensitive in partial-thickness tears
- Meta-analyses report a sensitivity of 87-92% for full-thickness tears with specificity of 93-96%, which is comparable to MRI 4,10,11
- MR arthrography is more sensitive and specific than both MR and US for identifying partial tears 2
- US is comparable to MRI in the hands of an experienced user. 10 US may be considered for the initial imaging investigation if rotator cuff pathology is suspected 1,12
- May also be considered in the evaluation of patients >40 years of age with primary traumatic anterior shoulder dislocation as rotator cuff tear is more common in this age group 13,14
- Useful in guiding aspiration of calcium deposits or bursal injections
- Useful in evaluating the long head of biceps tendon, though MR and US are both less accurate for biceps tendon pathology compared to rotator cuff injuries 2
- There is evidence that US is useful in guiding clinical decision making, 15 although a small prospective cohort study found no difference between outcomes in patients who received usual conservative treatment and patients whose treatment was tailored based on pathology found on US. 16 Additionally a group of patients recovered from their injuries before being randomised. These findings support guidelines that suggest initial conservative management before proceeding to imaging 16
- Advantages: no ionising radiation, non-invasive, no contrast agent, relatively inexpensive, readily available
- Limitations:
- Operator-dependent
- Less sensitive in detecting partial thickness rotator cuff tears
- Cannot accurately evaluate the labral-ligamentous complex and other deep shoulder structures
mri
Magnetic Resonance Imaging (MRI)
- MRI and ultrasound (US) are both useful investigations to assess impingement or rotator cuff tears 1,2
- Further imaging studies should only be considered if they are likely to provide additional clinical information which could potentially alter treatment 17,18
- MRI allows accurate assessment of soft tissue injuries and has significant clinical impact 4
- If no cause for pain is demonstrated, then additional information may be obtained by proceeding to MR arthography 19
- Highly accurate in the assessment of full thickness rotator cuff tears, with sensitivity of 89-94% and specificity of 93% 4,10,11
- Equally sensitive as MR arthrography with comparable in clinical impact for full thickness rotator cuff tears, but less accurate in the detection of partial-thickness tears 10,11
- Comparable accuracy to US in the assessment of both full and partial thickness rotator cuff tears 4,10,11
- Indicated in the investigation of rotator cuff disease when US expertise is unavailable or when further investigation of rotator cuff pathology is needed
- Advantages:
- No ionising radiation
- Non-invasive
- Demonstrates other lesions such as acromioclavicular joint osteoarthritis, occult fractures and avascular necrosis
- Comprehensive display of soft tissue anatomy
- Demonstration of the causes for impingement
- Useful in characterisation and staging of bone tumours
- Limitations:
- Can be less useful than MR arthography for evaluating labral tears 19-22
- Cost
- May not be tolerated in claustrophobia, contraindicated with ferromagnetic prostheses
mriarth
MRI Arthrography
- Involves an MRI following the intra-articular injection of a dilute contrast agent (gadolinium)
- When MRI is inconclusive, MR arthography is a useful problem-solving tool to assess labral pathology 1,2,19,21,23
- Most accurate imaging modality for defining:
- Rotator cuff pathology
- 94-95% sensitive and 93-99% specific for full thickness tears, and 62-86% sensitive and 47-96% specific for partial thickness tears 10,11
- Superior depiction of partial-thickness tears compared to conventional MRI 10,11
- MR arthrography is less sensitive for bursal-sided partial thickness tears than articular-sided partial thickness tears 24
- Labral/capsule abnormalities in gleno-humeral instability 25,26
- Rotator cuff pathology
- Minimally invasive but most patients find MR arthography less painful than expected 27
- Disadvantages: invasive, limited availability and high expense. Some studies report limited clinical value in patients already destined for arthroscopy 28,29
References
References
Date of literature search: April-August 2018
The search methodology is available on request. Email
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- American College of Radiology. ACR Appropriateness criteria. Shoulder pain - Atraumatic. 2018. (Guidelines). View the reference
- Tuite MJ, Small KM. Imaging evaluation of nonacute shoulder pain. AJR Am J Roentgenol. 2017;209(3):525-33. (Review article). View the reference
- Burbank KM, Stevenson JH, Czarnecki GR, Dorfman J. Chronic shoulder pain: part I. Evaluation and diagnosis. Am Fam Physician. 2008;77(4):453-60. (Review article). View the reference
- Dinnes J, Loveman E, McIntyre L, Waugh N. The effectiveness of diagnostic tests for the assessment of shoulder pain due to soft tissue disorders: a systematic review. Health Technol Assess. 2003;7(29):iii, 1-166. (Level II evidence). View the reference
- Goud A, Segal D, Hedayati P, Pan JJ, Weissman BN. Radiographic evaluation of the shoulder. Eur J Radiol. 2008;68(1):2-15. (Review article). View the reference
- Calcei JG, Boddapati V, Altchek DW, Camp CL, Dines JS. Diagnosis and treatment of injuries to the biceps and superior labral complex in overhead athletes. Curr Rev Musculoskelet Med. 2018;11(1):63-71. View the reference
- Feder OI, Levy BJ, Gruson KI. Routine plain radiographs in the setting of atraumatic shoulder pain: are they useful? J Am Acad Orthop Surg. 2018;26(8):287-93. (Level II-III evidence). View the reference
- American College of Radiology. ACR Appropriateness criteria. Shoulder pain - traumatic. 2017. (Guidelines). View the reference
- Nazarian LN, Jacobson JA, Benson CB, Bancroft LW, Bedi A, McShane JM, et al. Imaging algorithms for evaluating suspected rotator cuff disease: Society of Radiologists in Ultrasound consensus conference statement. Radiology. 2013;267(2):589-95. (Guidelines). View the reference
- de Jesus JO, Parker L, Frangos AJ, Nazarian LN. Accuracy of MRI, MR arthrography, and ultrasound in the diagnosis of rotator cuff tears: a meta-analysis. AJR Am J Roentgenol. 2009;192(6):1701-7. (Level I evidence). View the reference
- Lenza M, Buchbinder R, Takwoingi Y, Johnston RV, Hanchard NC, Faloppa F. Magnetic resonance imaging, magnetic resonance arthrography and ultrasonography for assessing rotator cuff tears in people with shoulder pain for whom surgery is being considered. Cochrane Database Syst Rev. 2013(9):Cd009020. (Level I evidence). View the reference
- Singh A, Thukral CL, Gupta K, Singh MI, Lata S, Arora RK. Role and correlation of high resolution ultrasound and magnetic resonance imaging in evaluation of patients with shoulder pain. Polish Journal of Radiology. 2017;82:410-7. (Level III evidence). View the reference
- Berbig R, Weishaupt D, Prim J, Shahin O. Primary anterior shoulder dislocation and rotator cuff tears. J Shoulder Elbow Surg. 1999;8(3):220-5. (Level II-III evidence). View the reference
- Pevny T, Hunter RE, Freeman JR. Primary traumatic anterior shoulder dislocation in patients 40 years of age and older. Arthroscopy. 1998;14(3):289-94. (Level III evidence). View the reference
- Friedman MV, Hillen TJ, Holland DV, Essenberg JM, Demertzis JL. Impact of shoulder sonography on clinical decision making. J Ultrasound Med. 2017;36(7):1365-71. (Level II evidence). View the reference
- Tran G, Hensor EMA, Ray A, Kingsbury SR, O’Connor P, Conaghan PG. Ultrasound-detected pathologies cluster into groups with different clinical outcomes: data from 3000 community referrals for shoulder pain. Arthritis Res Ther. 2017;19:30. (Level II-III evidence). View the reference
- Brun S. Shoulder injuries. Management in general practice. Aust Fam Physician. 2012;41:217-20. (Review article). View the reference
- University of New South Wales. Management of rotator cuff syndrome in the workplace. 2013. (Guideline). View the reference
- Magee T. Utility of pre- and post-MR arthrogram imaging of the shoulder: effect on patient care. Br J Radiol. 2016;89(1062):20160028. (Level II evidence). View the reference
- Bhatnagar A, Bhonsle S, Mehta S. Correlation between MRI and arthroscopy in diagnosis of shoulder pathology. J Clin Diagn Res. 2016;10(2):Rc18-21. View the reference
- Symanski JS, Subhas N, Babb J, Nicholson J, Gyftopoulos S. Diagnosis of superior labrum anterior-to-posterior tears by using MR imaging and MR arthrography: a systematic review and meta-analysis. Radiology. 2017;285(1):101-13. View the reference
- Yildiz F, Bilsel K, Pulatkan A, Uzer G, Aralasmak A, Atay M. Reliability of magnetic resonance imaging versus arthroscopy for the diagnosis and classification of superior glenoid labrum anterior to posterior lesions. Arch Orthop Trauma Surg. 2017;137(2):241-7. (Level II evidence). View the reference
- Grubin J, Maderazo A, Fitzpatrick D. Imaging evaluation of superior labral anteroposterior (SLAP) tears. Am J Orthop. 2015;44(10):476-7. (Review article). View the reference
- Chun KA, Kim MS, Kim YJ. Comparisons of the various partial-thickness rotator cuff tears on MR arthrography and arthroscopic correlation. Korean J Radiol. 2010;11(5):528-35. (Level II evidence). View the reference
- Smith TO, Drew BT, Toms AP. A meta-analysis of the diagnostic test accuracy of MRA and MRI for the detection of glenoid labral injury. Arch Orthop Trauma Surg. 2012;132(7):905-19. (Level I evidence). View the reference
- Jana M, Srivastava DN, Sharma R, Gamanagatti S, Nag HL, Mittal R, et al. Magnetic resonance arthrography for assessing severity of glenohumeral labroligamentous lesions. Journal of orthopaedic surgery (Hong Kong). 2012;20(2):230-5. (Level II-III evidence). View the reference
- do Nascimento PCX, Amaral AM, de Almeida JRM. Magnetic resonance arthrography of the shoulder: a painful procedure? Radiologia brasileira. 2018;51(2):81-6. (Level III evidence). View the reference
- van der Veen HC, Collins JP, Rijk PC. Value of magnetic resonance arthrography in post-traumatic anterior shoulder instability prior to arthroscopy: a prospective evaluation of MRA versus arthroscopy. Arch Orthop Trauma Surg. 2012;132(3):371-5. (Level II-III evidence). View the reference
- Jonas SC, Walton MJ, Sarangi PP. Is MRA an unnecessary expense in the management of a clinically unstable shoulder? A comparison of MRA and arthroscopic findings in 90 patients. Acta Orthop. 2012;83(3):267-70. (Level III evidence). View the reference
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