Shoulder pain: The influence of imaging and diagnostic labels
How often does a patient present to you in clinic with an imaging report ordered by a GP, (or other practitioner) But the practitioner has not taken the time to go through the report and educate the patient on what it means using normalising / unthreatening terminology. There is often terminology like “partial thickness tear” “full thickness tear”, “bone spurring”, “osteoarthritis” etc the problem with this is that this immediately send alarm bells ringing and the patient fears the worst “it’s only going to get worse” “now I feel like its just hanging on my a thread” “I’m going to need surgery” “I need to stop using my shoulder”
What was once an uncomfortable shoulder pain, now has greater psychological impact that can lead to influencing a patient’s thoughts, beliefs, fears, behaviour, and emotions.
Without appropriate education from ‘US’ the clinician, it can lead the patient down a long path of mismanagement and chronic pain.
EDUCATION IS KEY!
In non-traumatic shoulder pain, many of these imaging finding are completely normal age-related changes. YES, that’s right it can be completely normal to have tears, bone spurring, OA, bursal thickening, tendinopathic changes and be completely asymptomatic!
Often they do not need to be rushed off to an Orthopaedic Surgeon or to a Sports Physician for a corticosteroid injection.
What they will benefit from is reassurance, and a MINUMUM 12-week conservative management plan with progressive loading. YES, you will also need to screen for red & yellow flags and potentially engage a multidisciplinary team in the management. What they don’t need is imaging for non-traumatic shoulder pain to detect incidental findings that can impair patient outcomes, by providing diagnostic labels that are often a barrier to recovery.
What WE often don’t appreciate is how our language and the use of medical terminology can be misinterpreted by a patient leading to catastrophisation and avoidance.
Understanding prevalence of these pathological changes is key. Pathological findings in the shoulder are highly prevalent in adults aged 40 years and older. Minagawa et al. found that the prevalence of rotator cuff tear in the general population was 22.1%, which increased with age. Asymptomatic tears were twice as common as a symptomatic tear.
WE need to be discussing the patient’s beliefs about their diagnosis and what it means to them. Understanding this is a key place to start by challenging these unhelpful cognitions and creating a strategy to overcome these barriers.
Pathological finding are highly prevalent in asymptomatic patients and even in the opposite asymptomatic shoulder on the same patient. This should give us and the patient confidence that we don’t need full resolution of these changes identified on MRI for a patient to be pain free. These changes can be very normal and very common and they don’t need to “fixed” with surgery. It is widely recognised that there is a poor correlation with pathology and pain or function, however the risk of developing symptoms in the future may increase.
Patients with non-traumatic shoulder pain often do not need surgery for many of these normal age-related changes. There is extensive evidence demonstrating that conservative management is as good as, if not better than CSI and surgical intervention at long term follow up, AND conservative management is far more cost effective! (There are of course instances where surgery may be indicated, however in the majority of cases, conservative management with progressive exercise is most effective)
Explaining why you are not concerned about these imaging findings is key.
“In-fact this looks pretty good for someone of your age / level of exercise history / occupation etc” “Your shoulder is sensitised, but the good news is, these changes respond really well to movement and exercise” “Let’s get you more comfortable with movement” “Lets build the capacity of your tissue to allow you to overcome these symptoms”.
The management of rotator cuff related shoulder pain takes time, progression and perseverance. There will be good days and bad days there may be psychosocial influences that are contributing to their pain experience that also need to be identified and managed and not just the pain or pathology in isolation.
Got a great story or example of how you’ve succeeded (or perhaps struggled) with this? I’d love for you to share it with me. Send me an email to bodine@advancedclinicaled.com.
Yours in health,
Bodine Ledden.
