Not me personally (or at least not that I know about), but this is something I occasionally hear from patients with shoulder pain. Typically these patients are over 60 and don’t have a traumatic incident that caused their shoulder pain (e.g. a fall on an outstretched hand), yet when they initially sought care from their medical doctor a MRI was promptly ordered. What it showed was a partial thickness (or sometimes full thickness) tear of one of their rotator cuff tendons, and this finding was assigned blame for their symptoms. Based on this information, treatment (e.g. surgery, physical therapy, etc.) was directed at the tear.
At first glance this seems like a rational thought process and solid clinical decision making, until you delve deeper into research that has been conducted in recent years.
- In the study, Abnormal findings on magnetic resonance images of asymptomatic shoulders, 34% (33/96) of asymptomatic individuals had a partial or full thickness tear of their rotator cuff tendon on MRI. Over half of those with a rotator cuff tear were over the age of 60.
- In the study, Ultrasound of the Shoulder: Asymptomatic Findings in Men, 51 asymptomatic individuals (aged 40-70) had one shoulder imaged via ultrasound. 22% (11/51) of the shoulders imaged had a partial rotator cuff tear, and 96% (49/51) of all shoulders assessed had some form of abnormality on ultrasound, again with no symptoms present.
- In the study Prevalence of symptomatic and asymptomatic rotator cuff tears in the general population: From mass-screening in one village, 22.1% (147/664 had a rotator cuff tear) of the individuals assessed via ultrasound had a full thickness rotator cuff tear. No one under the age of 40 had a tear, however, and the incidence climbed in each decade from the 50 onward. The study also found that tears in asymptomatic individuals were twice as prevalent as tears in symptomatic individuals.
Based on these studies, and there are many more that tell the same story about rotator cuff tears, the question that needs to be asked is “If these findings are so common in people without shoulder pain, how do we know if they are relevant in people with shoulder pain?” This question is similar to the one that was asked in a recent blog post about spinal “pathology” (e.g. disc degeneration, spondylolisthesis, disc bulges, etc.) found on the MRIs and x-rays of people who have never had back pain.
Now I am not saying that rotator cuff tears aren’t sometimes the cause of shoulder pain. If you have a traumatic shoulder injury which has the clinical signs and symptoms of a rotator cuff tear, confirmed with MRI imaging, you should get the tear addressed. What I am saying is that even though someone with shoulder pain has a non-traumatic rotator cuff tear on imaging (e.g. MRI or ultrasound), they should still be assessed to determine if the tear is the cause of their pain or not. The MRI or ultrasound alone can’t give you this information because, as we just saw, tears exist in both asymptomatic and symptomatic patients and, according to the third study summarized above, are more common in those without shoulder pain.
A McKenzie Method (Mechanical Diagnosis and Therapy – MDT) assessment is well suited to determine if the tendon is the cause of shoulder pain (as opposed to the shoulder joint itself or even the cervical or thoracic spine), and if non-surgical treatment is indicated. Great decisions begin with an assessment process, which ultimately guides treatment. Assessment by a McKenzie (MDT) trained clinician can help to determine your pain generator and how to treat, and therefore increase the likelihood of a favorable outcome.