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  • Dr. Piotr Solowiej PT, DPT

Special Tests, Aren't so Special. Neither is Your Imaging.

Shoulder-MRI-rotator cuff

As a former high school baseball player, and currently a recreational rock climber, the shoulder is hands down my favorite joint to treat. It is a complex joint in terms of structure, which has led to many [failed] attempts to identify concrete causes to shoulder pain.

However, as Adam Meakins says, complex does not have to be complicated. (For any other PT's reading, check out Adam's shoulder course. He does a fantastic job of simplifying assessment and treatment of shoulder cases).

For example, there are numerous 'special tests' that claim to identify a single structure as the cause of a person's pain. The reality is, is that these tests aren't so special and do a very poor job of what they claim to do.

Due to that structural complexity, it is impossible to single out any one structure on manual examination to confidently say "x" is the cause of your pain. There is too much overlap of structures.

In addition to not-so-special tests, another favorite of the healthcare establishment is utilize imaging (MRI, X-Ray, Ultrasound, etc...) as evidence for the cause of pain. Guess what? Imaging alone also does a poor job of correlating 'abnormal' findings with pain.

Take rotator cuff tears for example. Historically the scapegoat for shoulder pain, they are no longer thought to be the dire culprit they once were. Take this study, where an entire village of people (664) had both their shoulders scanned to assess if a rotator cuff tear, identified on imaging, would correlate with subjective reports of pain.

Their findings?

The ultrasound showed 147/664 of the individual had full thickness rotator cuff tears. Prevalence increased with age, and only 34.7% of those full tears were symptomatic. 65.3% had no symptoms whatsoever. It is actually the norm to not have pain with a rotator cuff tear.

Does that mean that a tear could never cause a person pain? Of course not. If there is a clear trauma or event associated with the onset of pain, it is more likely that the tear is the cause and would likely benefit from surgical intervention. Notice the emphasis on likely. The only sure way to know, in my mind, would be to compare imaging of the shoulder before and after said event. But that's not exactly realistic and I imagine there would be some degree of uncertainty there as well.

It is frustrating to see how antiquated schools of thought are continually utilized in the healthcare system, because they are misleading patients and practitioners alike. Reliance on patho-anatomical diagnosis results in over utilization of invasive procedures, like surgery.

Again, there are certainly cases where it is appropriate, but as one of the most costly healthcare systems in the world, we have to do a better job of identifying people that are not appropriate for invasive intervention.

What has been found to be successful in the vast majority of cases, is exercise and strengthening of the shoulder joint musculature.

Watch the video below to hear Dr. Jeremy Lewis talk in detail about just how effective exercise can be in comparison to surgery.

Thanks for reading,

Dr. Piotr Solowiej PT, DPT

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