‘Little benefit’ in early scans for shoulder pain

As the third most common musculoskeletal presentation in primary care after back and knee conditions, management of shoulder pain is common for GPs.
 
Now, experts are questioning the status quo and recommending that routine scans for shoulder pain be scrapped, calling instead for a better understanding of the patient’s symptoms and history, and timely self-management.
 
A team from Monash University has published a review on existing evidence, concluding that most shoulder problems improve with ‘simple supportive care’, education and time, rather than a reliance on unnecessary early scans and surgical interventions.
 
Routine scans including X-rays, ultrasounds or MRIs are not necessary for most patients experiencing subacromial pain, they state, as what appears on a scan often does not explain the patient’s pain.
 
The review authors instead recommend GPs conduct a physical examination, reassure patients about their expected recovery, and provide advice on activity modifications, symptom relief or a ‘wait-and-see approach’ where appropriate.
 
Although noting that causes of shoulder pain vary, they state initial management is ‘largely the same once serious conditions have been excluded’ and most patients with subacromial pain will ‘fully recover with minimal intervention and can be safely treated with supportive care’.
 
Imaging and referral to surgical sub-specialists should be reserved for ‘rare and carefully selected cases’ to avoid unnecessary intervention.
 
Lead author Dr Romi Haas points to evidence against routine imaging, saying the standard approach may cause undue patient worry, overdiagnosis and unnecessary treatments.
 
‘Most cases of shoulder pain can be safely managed by a GP without the need for routine imaging or specialist referral,’ she told newsGP.
 
‘Instead, GPs should first focus on ruling out serious underlying causes, such as broken bones, tumours or infections, using a thorough history and clinical examination.
 
‘The traditional approach has been to look for a structural flaw by scanning the shoulder assuming that if you can identify the source of pain, you can fix it.
 
‘However, our review explains that abnormalities seen on a scan are exceedingly common in people without shoulder pain and are often just a normal and harmless sign of ageing (similar to grey hair or wrinkles). This makes it virtually impossible for a scan to tell us what’s actually causing the pain or what is completely harmless.’
 
Importantly, Dr Haas says the review’s findings show that having an early scan such as an MRI does not improve long-term recovery, and provides GPs with the evidence to reassure patients that self-management, targeted advice and time are ‘usually’ the safest and most effective path to recovery.
 
‘Explaining this to patients may be needed to reassure them, reduce anxiety and avoid expectations for unnecessary imaging or surgical procedures,’ she said.
 
‘And reframe diagnosis: after ruling out serious underlying causes, first-line management should include reassurance that most people improve naturally over the course of time, activity modification and pain relief.’
 
The RACGP’s First do no harm: A guide to choosing wisely in general practice aims to facilitate shared decisions about health, with a focus on overdiagnosis, interventions with insufficient evidence and overused tests that can potentially lead to patient harm and wasted resources.
 
The guide’s resource on imaging in adults with acute low back pain states that unnecessary diagnostic imaging causes more harm than benefit and can lead to unnecessary referrals, procedures and surgery.
 
Associate Professor Michael Tam sits on the RACGP Expert Committee – Quality Care and is co-Chair of the First do no harm guide. He says the findings from the review can support GPs in managing subacromial pain.
 
‘In the absence of any concerning features, there is generally little benefit to the patient in early imaging of the shoulder,’ he told newsGP.
 
‘Most shoulder pain is benign, self-limiting, and involves the soft tissues around the shoulder joint.
 
For the most part, the overarching treatment for the common conditions that cause shoulder pain is similar – education and reassurance, symptom management, and activity modification until recovery.
 
‘There are of course, less common and more serious causes that will require further assessment, and much of this will be identified through history taking and physical examination.’
 
The review supports calls to reduce overused tests and interventions, Dr Haas says, with GPs’ active role ‘remaining essential’.
 
‘Reducing overuse doesn’t mean do nothing – GPs must still rule out serious pathology, monitor progress, offer pain relief and provide ongoing reassurance as required,’ she said.
 
‘Our review highlights specific tests and treatments that have been shown to offer little to no benefit over placebo, not just simply a lack of research.’
 
Dr Haas also says the same principle applies to corticosteroid injections and surgery for management of shoulder pain.
 
‘When corticosteroid injections are indicated for short-term pain relief, evidence shows that using a patient’s physical anatomy to guide the position of the injection works just as well as image guidance, eliminating unnecessary delays and costs,’ she said.
 
‘And subacromial decompression surgery provides no meaningful benefit over placebo surgery or non-operative management, meaning that in most cases it is no benefit.
 
‘This reminds us that pain isn’t always caused by an anatomical or structural problem that can be fixed with surgery.’
 
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