A patient arrives at the office of Lauren Simon, MD, MPH, expecting to receive MRI for their newly developed shoulder pain. Instead, Simon reaches for a pen and begins taking a history.

There is no scan to order, procedure to schedule, or structural issue to fix — evidence shows that new shoulder pain rarely requires imaging or aggressive intervention.

“In the absence of trauma or red flags, I explain to patients that imaging is not indicated at this time,” said Simon, a professor of family medicine and director of primary care sports medicine at Loma Linda University in Loma Linda, California. “Then we discuss conservative care such as analgesics and therapeutic exercises and perhaps activity modification with a plan to reassess their pain.”

For most cases of shoulder pain not the result from a major injury, the better first step is to rule out serious conditions, offer reassurance, manage symptoms, and give the joint time to recover, according to a new clinical review published in JAMA Internal Medicine.

“Unwarranted imaging may lead to overdiagnosis, patient anxiety, and overtreatment,” said Rachelle Buchbinder, MBBS, PhD, a rheumatologist and director of the Department of Clinical Epidemiology at Monash University in Melbourne, Australia, who led the review.

A Common Problem With a Favorable Prognosis

Shoulder pain affects an estimated 16% of adults annually and is the third most common musculoskeletal complaint seen in primary care. But most cases of shoulder pain in primary care are not caused by a specific injury. Instead, the root cause often involves muscles, tendons, or other soft tissues.

Even if a specific structural problem is identified “there is no way really of knowing if these structural changes are the cause of the pain or not,” Buchbinder said. Imaging often detects changes in the shoulder also present in people without pain. And any findings do not necessarily explain a patient’s symptoms.

Buchbinder and her colleagues suggest using the broader term subacromial pain rather than attempting to make a diagnosis of rotator cuff tendinopathy or impingement syndrome, which are commonly inconsistently defined.

Imaging is also not reliable in showing the cause of pain. For instance, rotator cuff tears can occur without symptoms, especially as a person ages, said Dave Pavao, PT, DPT, a spokesperson for the American Physical Therapy Association and clinical officer of Highbar Physical Therapy in Rhode Island, who was not involved in the clinical review. Instead, clinicians should consider a patient’s health history, symptoms, function, movement, and goals.

When Imaging Makes Sense

Simon first considers red flags that might warrant imaging, such as fever, night sweats, unexplained weight loss, a history of cancer, intravenous drug use, and traumatic injury.

Sudden, severe pain accompanied by redness or warmth can signal a septic joint and requires prompt evaluation. Neurologic findings, muscle wasting, or symptoms involving other joints can point to a problem outside the shoulder.

Imaging may be appropriate when clinicians suspect a serious problem, when symptoms fail to improve, or with significant or worsening weakness, Buchbinder said.

When imaging is warranted, an x-ray is generally the starting point. Ultrasound may be appropriate when a closer look at the soft tissues could change treatment.

An MRI is most useful when clinicians already have an idea of what might be wrong and need more information to guide next steps, said Anthony Miniaci, MD, deputy chief medical executive of Baptist Health Orthopedic Care in Florida and president of the physician group American Shoulder and Elbow Surgeons.

“The MRI is really for confirmation,” Miniaci said. “It’s very important that they go through the steps in the process so that they see whether they’re going to be able to be managed conservatively without surgical management or not,” Miniaci said.

Treatment: Less May Mean More

For most patients with subacromial pain, initial treatment includes education, reassurance, activity modification, symptom relief, and watchful waiting. But this conservative approach may be difficult to communicate to a patient who wants a diagnosis and an aggressive treatment plan.

Clinicians can start by explaining that shoulder pain is common and usually improves, Buchbinder said. About 95% of patients improve within a year, with many recovering earlier, the review found. Treatments such as cortisone injections generally do not alleviate symptoms more quickly.

Physical therapy also plays an important role. One study suggested a single physical therapy session providing advice, simple home exercises, and guidance was as effective as a six-session supervised exercise program by physical therapists.

Treatment, physical therapy, and recovery “can vary considerably,” depending on the severity of the problem, a patient’s history, and other health conditions, Pavao said.

“For some patients, a single PT visit that provides education and an individualized exercise plan may be enough,” he said. Others may benefit from ongoing support as they return to their usual activities.

For most patients, “movement is medicine,” he said. They should continue to keep their shoulder active, even if mild discomfort presents. Progressively worsening pain or significant loss of function, however, should prompt reassessment, he said.

Simon takes a similar approach. When patients need more help with range of motion or specific exercises, she may refer them for a brief course of physical therapy. Otherwise, she often recommends avoiding movements that aggravate the shoulder.

Topical nonsteroidal anti-inflammatory drugs are a reasonable first-line medication option, according to the review. However, oral versions may provide modest short-term benefit and require consideration of potential harms such as interactions with other medications. Opioids are not recommended.

For moderate-to-severe pain, particularly substantial pain at night, a landmark-guided subacromial glucocorticoid injection may provide short-term relief. Hyaluronic acid and platelet-rich plasma injections are not recommended as studies have not demonstrated meaningful benefit over placebo.

Rethinking Surgery

Surgery enters the conversation only after a patient has had a 6- to 12-week trial of nonsurgical treatment and physical therapy, Miniaci said.

“Once the decision for surgery has been made, that’s just the beginning,” Miniaci said, adding that patients still face rehabilitation and recovery after the procedure.

For shoulder pain without a full-thickness rotator cuff tear shown through imaging, subacromial decompression surgery is no longer recommended. Evidence supporting surgery over nonoperative treatment remains uncertain, especially among older adults with smaller degenerative tears, according to the review.

Some conditions, including shoulder osteoarthritis and frozen shoulder, may require different treatment such as pain relief or anti-inflammation injections, Buchbinder said.

But for the patient with a new, nontraumatic sore shoulder sitting in Simon’s exam room, the answer may be much less dramatic.

Her patients receive an examination to make sure nothing serious is missed, a plan for pain management, and a conversation about what to expect.

Sometimes, Simon said, the most useful thing a clinician can offer is reassurance that the shoulder can get better on its own.

“Many of the patients will get resolution of their shoulder pain over time with conservative care,” Simon said.

Buchbinder, Pavao, and Simon reported having no relevant disclosures.

Lara Salahi is a health journalist based in Boston.