​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:

1. How the pain began- was it traumatic or did it start gradually over time?
2. Is the pain constant, getting worse, or slowly improving?
3. When is the pain present? Does the arm hurt mainly at night?
4. Is there anything that the patient does to make the shoulder pain better?
5. How severe is the pain during common tasks such as dressing, reaching, driving?

Physical examination includes:

1. Assessment of active motion- how far the shoulder moves in each direction?
2. Assessment of muscle strength- applying a consistent force to each muscle group to gauge its ability to contract under tension.
3. Assessment of joint mobility- Passively moving the joint in different planes to gauge the end feel of the joint.
4. 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 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.html 

For more on this topic, check out our YouTube Curiosity Corner. Or give us a call to set up a visit: 331-253-2426
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By Dr. Sarah Greenwell, PT, DPT, CSMPT

​I listened to a podcast recently where the speaker mentioned that the more invasive a treatment is, the more expectation there is for improvement. In our culture, we generally consider surgery to be the gold standard fix for an orthopedic problem, followed by a shot, a pill, and rehab.
We also live in a culture that wants immediate results.

The problem is that orthopedic surgery can sometimes do more harm than good. (https://theconversation.com/3-orthopaedic-surgeries-that-might-be-doing-patients-and-their-pockets-more-harm-than-good-179370) And other times, it has been proven in research to be no better than conservative rehabilitation. In some cases, short term results are seen but... many times long term results are often the same.

We really should be asking ourselves is the cost is worth the outcome? And that cost includes the financial burden of surgery; time off work, sports, exercise, recreational activities with family; and cost of the rehab often needed following the surgery. Not to mention the temporary increase in pain immediately following a surgical procedure, the impact it can have on sleep for several days to weeks following the procedure, risk of complications on the operating table, blood clot or infection risk during recovery, and often the need for help from friends and family for basic self-care and driving in the early days post-op.
Dr Travis Maak on the JOSPT Insights podcast even said that most surgeons will prefer to avoid surgery. They recommend conservative care first. I once had an orthopedic surgeon who performs total knee replacements on a daily basis, tell me that he personally would never have the procedure because he has seen some of the bad complications.

Converse to the complications from surgery, the side effects of physical therapy -specifically exercise- can include: improved strength, flexibility, cardiovascular function, weight management; improved balance, bone health, endurance, mood; improved blood pressure and cholesterol; improved circulation; reduced stress; improved posture. Doesn't sound too bad does it? 

The catch – it sometimes takes time and consistency. Based on the severity of pain, how long it has been a problem, and the underlying cause: some patients get pain relief in the first 2-4 therapy sessions. For others, it takes more time. But for everyone, true improvements in strength and tissue health take at least 6-8 weeks. If you want to fix the underlying problem and keep it from coming back, you need to put in the work and time. We have a quote on our clinic wall that says:

This is not to say that surgery is never appropriate or helpful. There are certainly times when surgery is the best option. But for most orthopedic injuries, 6-8 weeks of conservative therapy should be tried first. And not the kind that you just show up and someone else does a bunch of passive treatments (ultrasound, electric stimulation, massage and stretching only) – but the kind that makes you work!

If it doesn’t challenge you, it won’t change you.

Put in the effort to help accelerate the tissue healing, and build a better foundation for future performance! 

If you or someone you know is dealing with an orthopedic issue and you are considering surgery or wondering what other options you have, you can reach out to us via email, info@recoverrxpt.com, give us a call 3312532426, or sign up for a Free Discovery Visit to see if our personalize therapy can help. 

Thanks for reading!
Dr. Sarah