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Diagnosing Shoulder pains and imaging

Samuel Sunday - 01:27:00

Diagnosing Shoulder pains or injuries using Imaging

Shoulder pains has always been a problem to many people and this is also why shoulder pains has recorded a leading cause of musculoskeletal disorder. Shoulder pains can rob one the free socket rotation of the shoulder and over time can result in long term physical disorder or disability.  
Pathologies or disorders affecting the shoulder function 
The primary disorder of the shoulder is pains while secondary include ;
  • Rotatory cuff tear (RCT) 
  • Glenohumeral Osteoarthritis (AO) 
  • Traumatic Instability (I)
  • Adhesive Capsulitis (AC) 


Diagnosis of Shoulder Pain and other Pathology 

Diagnosing a shoulder pain requires the physiology and anatomy of the shoulder which will be challenging or not even possible in the presence of many or multiple shoulder pathologies because of how complex the shoulder is in its operations and arrangement of the parts. 

Pains in the shoulder region

Process of Shoulder Pain Diagnosis 

To be able to diagnose a shoulder pathological, patient's shoulder is evaluated for physical damage which may then be followed by imaging to verify the diagnosis. If necessary the patient is referred to an orthopedic expert for treatment.  

Advanced imaging techniques is considered to confer added benefit while increasing the diagnostic accuracy. However there have been several studies regarding this claim and that the use of additional imaging or specialist will rather have a reduced impact on the care patients receive. Thus the increased demand for advanced imaging and subsequent specialist referral may serve little purpose and may increase wait times for these services. Believing that a stringent evaluation of advanced imaging and referral patterns in assessing shoulder pain would be of value, Dr. Geoff and friends proposed a study to investigate the assessment of common shoulder pathologies encountered in the primary care setting. 

The study also sought to analyze imaging relevance and diagnostic concordance between referring physicians and orthopaedic surgeons. Other outcomes proposed included the wait time between referral and orthopaedic assessment, and the percentage of surgical referrals. They also  hypothesized a discordance between referring and orthopaedic specialist diagnoses.

 Dr. Geoff and friends conducted a retrospective, observational cohort study utilizing 150 patient chart reviews to compare the diagnoses of referring physicians with the diagnoses of an orthopaedic specialist. Their study included all patients referred to the practice of a single shoulder surgeon between January 2011 and May 2015. Patients were identified through an electronic medical record system (Plexia) using International Classification of Diseases codes for four common shoulder pathologies: rotator cuff tear, glenohumeral osteoarthritis, instability, and adhesive capsulitis. Primary outcome measures were referring diagnoses and imaging studies available at the time of referral, and the final diagnoses determined by the orthopaedic specialist. Imaging studies ordered by the referring physicians were classified as “indicated” based on standard orthopaedic management or as “not medically indicated” (beyond what is necessary for diagnosis or treatment). “Underinvestigated” was used to describe the absence of imaging considered relevant to establishing a diagnosis. In addition, surgical cases extracted from the referral database were recorded and referral wait times were determined.

 Depending on the shoulder pathology, the referring diagnosis corresponded to the specialist diagnosis from 21% to 97% of the time. The most common example of imaging deemed not medically indicated was the use of MRI for suspected adhesive capsulitis. The most common example of underinvestigation was the lack of X-ray images for the four shoulder pathologies studied. The mean wait time to see an orthopaedic specialist following referral was 138 (99) days. The result of this study made Dr. Geoff and his friends highlight the need for improved collaboration between the primary care physician and orthopaedic specialist regarding common shoulder pathologies and use of imaging studies.

Further Reading 
Geoff C. Jarvie. Jeffrey M. Pike. Danny P. Goel. 2017. Diagnoses and imaging utilization for common shoulder disorders by referring physicians in British Columbia. BCMJ. 59(4) pp.222-226.