Shoulder pain

Conservative Tx:

  • Simple neck x-ray
  • Refer to physiotherapy
  • Analgesics /NSAID

Referred pain
from neck 
/ trapezius

Conservative TX:

  • Inflammatory blood work
  • X-ray of suspicious zones
  • Refer to Physiotherapy / Rhumatalogy


+ History of surgery
+ Osteoarthritis
+ Bursitis
+ Acute capsulitis
+ Low velocity trauma

Impingement phenomenon

+ Impingement syndrome
+ Rotator cuff tear
+ Calcifies tendinitis
+ Tendinitis / Bursitis
+ Recurrent trauma


+ High velocity
+ Weakness on abduction
+ Drop arm

Smooth joint movement

+ AC-CL osteoarthritis
+ Shoulder tendinitis
+ Metastatis suspected
+ History of cancer

Joint instability

+ Subluxation
+ Luxation
+ Hyperlaxity of ligament

Conservative Tx:

  • 6 weeks Home exercises

Care by family
physician (option)

If symptoms
 ≥ 6 weeks

administer first
corticosteroid injection

Simple shoulder

  • Refer to physiotherapy
  • Rotator cuff strengthening exercises x 3 months minimum

If luxation
or physiotherapy


Results ?


Negative (-)
Positive (+)


+ In a patient < 60 years with suspected complete rotator cuff tear
- If no calcified tendinitis
- If no migration of humeral head/humeral cyst 
- If no shoulder osteoarthritis
+ Shoulder subluxation with failed medical treatment
+ Drop arm ≥ 6 weeks



If failed
shoulder pain
Shoulder Pain Algorithm
if failed

1) Shoulder pain is not an indication for MRI. Clinically, in frontline care, there are only two things to distinguish: actual abduction weakness and shoulder joint stiffness. Depending on the case, see the shoulder algorithm for treatment plan.

2) All patients who underwent shoulder surgery in the past should have an x-ray of their painful shoulder taken before being referred to orthopaedics if conservative treatment failed. It is not necessary to request an MRI scan before referring the patient to orthopaedics.

3) Frozen shoulder is associated with much stiffness and evolves in three phases of four to six months; it therefore lasts for a period of about one to two years.

4) The word “tendinopathy” includes tendinitis, partial rotator cuff tear, tendinosis, and calcified tendinitis of the rotator cuff. Conservative treatment applies to all these pathologies.

5) Rotator cuff tears are very common in older patients and often asymptomatic. Rotator cuff tears are generally unrepairable after the age of 75; so all investigations beyond standard x-rays and a good physical examination are useless to diagnose rotator cuff tears.

6) Rotator cuff tears often are asymptomatic, especially after the age of 60.

7) Cases of shoulder instability do not require an MRI scan before they are seen in orthopaedics. It is recommended to start physiotherapy before the orthopaedic consultation.

8) Smaller or partial cuff tears are treated like bursitis or tendinitis of the rotator cuffs. MRI is generally not required to make these differential diagnoses. They are clinical diagnosis.

9) Patients aged 60 and over often have asymptomatic cuff tears and only 55% have rotator cuffs that are repairable. However, surgery is only required if the patient is symptomatic.

10) Before requesting an MRI scan, the requester must have ordered a standard shoulder x-ray and seen the result. In case of acromio-clavicular joint osteoarthritis, tendinous calcification of the shoulder, and especially humeral head migration suggestive of a cuff tear, there is no use for MRI.

11) In frontline care, for a shoulder problem, start by initiating conservative treatment and evaluate the need for a standard x-ray of the shoulder. The priority should not be diagnosing a rotator cuff tear but ruling out shoulder calcification or osteoarthritis with an x-ray of the shoulder. In patients aged 60 and under, if conservative treatment with physiotherapy for at least three months failed, rule out rotator cuff tear if x-rays are normal, either with an orthopaedic consultation or an MRI scan.

12) Shoulder problems with tendinitis or impingement syndrome are responsive to physiotherapy treatment in 55% to 80% of cases according to the various studies. The symptoms of shoulder tendinitis last about six months.

13) Humeral head superior migration means an unrepairable, chronic, massive cuff tear; thus there is no indication for MRI given that a clinical and radiological diagnosis is made.

14) In traumatic circumstances, with a normal x-ray of the shoulder, in presence of clear arm weakness on abduction showing no improvement in time (four to six weeks) or after basic medical treatment (analgesics, NSAIDs, physiotherapy), an urgent orthopaedic consultation and MRI scan should be requested.

15) Surgical repair is not always possible for significant cuff tears, especially massive tears. However, acromioplasty may be considered to reduce subacromial impingement.

16) In non-traumatic circumstances, a subacromial corticosteroid injection is useful if symptoms are severe and debilitating in a patient who has shown symptoms for over four to six weeks with standard x-rays. There is an indication for corticosteroid injection if symptoms have been present for over three months and if they are mild to moderate, suggestive of cuff tendinopathy that was not responsive to physiotherapy.

17) Xylocaine or ropivacaine tests done by a specialist can replace MRI in surgical decision making for the shoulder.

18) In frontline care, the treatment plan should be reviewed before administering more than one corticosteroid injection in the shoulder, particularly if the rotator cuff is repairable.

19) There should be an interval of at least six weeks between shoulder corticosteroid injections for a maximum of three injections in a lifetime with a functional rotator cuff. If a physician has limited experience in administering injections, refer the patient to orthopaedics after the first injection.

20) Based on the principles of choosing wisely, there is no indication for a bilateral MRI scan of the shoulder. It is more economical to refer the patient to orthopaedics, physiatry, sports medicine, or physiotherapy to determine the course of action.

21) Cysts on the greater tuberosity and humeral head migration are associated with rotator cuff tears. Whether symptomatic or not, focus on conservative shoulder treatment. If there is functional impairment, surgical treatment should be considered.

22) Diagnosing a partial cuff tear is useless in presence of almost normal movement with no significant weakness. It should be treated as cuff tendinopathy. Impingement should be differentiated from weakness. The Xylocaine test is useful for this.

23) In an MVA context, an MRI scan of the shoulder is indicated if pain is localized in the shoulder only and shoulder symptoms have been persistent for over six weeks in spite of physiotherapy treatment. If there is trapezius/neck pain, it is a status post whiplash and conservative treatment should be chosen for neck problems. MRI is less useful if brachialgia symptoms are not associated with upper extremity weakness or paresthesia.

24) Given its high cost, an MRI scan with contrast to rule out labral tear in case of instability should be reserved for orthopaedics, sports medicine, or the pain management clinic team.