MRI Prior to Conservative Therapy Often Unnecessary for Atraumatic Shoulder Pain

Rotator cuff tears (RCTs) are quite common in otherwise healthy populations (34% in a study that included partial tears published by University of Miami researchers in The Journal of Bone and Joint Surgery), and the prevalence increases with age. But despite this fact, there are no clear guidelines about their evaluation and management.

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Based on clinical examination alone, it's exceedingly difficult to identify the type of shoulder injury in a patient who has pain but only slight physical deficits. U.S. clinicians often order an MRI at the initial presentation of suspected shoulder tendinopathy or shortly thereafter.

Based on data from a prospective study, Scott D. Martin, MD, director of the Joint Preservation Service within the Department of Orthopaedics Sports Medicine Center at Massachusetts General Hospital, and colleagues now call into question the use of MRI before a trial of conservative management in patients with atraumatic shoulder pain, minimal to no strength deficits and suspected cuff tendinopathy other than full-thickness tears. Their report appears in the Journal of Shoulder and Elbow Surgery.

Study Details

The researchers followed 51 adults who had a chief complaint of atraumatic anterolateral shoulder pain, strength test minimum score of 4 or 5, and screening radiographs exhibiting no to mild glenohumeral arthritis and no cuff arthropathy.

All patients were suspected to have cuff tendinopathy, but a full-thickness tear was considered unlikely in patients with relatively well-preserved strength testing. They underwent MRI or magnetic resonance arthrography (MRA) at an average of 10 days after presentation.

The patients tried conservative therapy for at least two months including patient education, activity modification, nonsteroidal anti-inflammatory drugs and physical therapy. Those with severe pain were offered an intra-articular steroid injection. If symptoms progressed or failed to improve, patients were given the option of rotator cuff repair surgery.

Need for Surgery

The average length of follow-up from MRI/MRA to chart review was 28 months. Over this period only five patients (10%) went on to surgical intervention. Thus, 46 patients had premature MRI/MRA that did not affect management.

Risk Factors for Surgery

Four of the five patients requiring surgery had full-thickness tears on MRI, and conversion to surgery was significantly associated with such a finding (P ≤ .001). There was borderline correlation between surgery and age (r = 0.274; P = .0518).

Thirty-three patients had concomitant labral pathology, but it was not a statistically significant risk factor for surgery.

A More Reasonable Approach

The patients who had surgery received it an average of 68 days after MRI/MRA. In retrospect, they could have tried 60 days of conservative therapy, undergone an MRI if symptoms persisted or progressed and received surgery within the same time frame. This seems to be a more reasonable approach, as it would have yielded similar results and posed much less financial burden to patients and the health care system.

Value in health care has been defined as outcome relative to costs. MRI is an exceptionally powerful diagnostic tool, but to translate into value, it must provide actionable information that influences management.

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