How to evaluate for scar tissue of the shoulder?

Evaluation of Shoulder Scar Tissue

MRI or MR arthrography is the optimal imaging modality for evaluating shoulder scar tissue, with MR arthrography being the gold standard for detecting labral tears and soft tissue pathology with 86-100% sensitivity. 1

Comprehensive Diagnostic Approach

Initial Imaging

1. Radiographs - First-line imaging for all shoulder pain 2, 1

   • Anteroposterior (AP) view in neutral position
   • Grashey view (AP with 30-45° posterior oblique)
   • Axillary lateral or scapular Y view
   • Special views as indicated (e.g., Rockwood view for impingement)

2. Advanced Imaging (based on radiograph findings)

   • MR arthrography - Gold standard (rated 9/9) for evaluating scar tissue and labral tears 2, 1
   • Standard MRI without contrast - Highly effective (rated 7/9) with optimized imaging equipment 2
   • CT arthrography - Third choice, only if MRI is contraindicated 2
   • Ultrasound - Limited role for scar tissue evaluation but useful for rotator cuff and biceps tendon assessment 1

Physical Examination

A thorough physical examination should accompany imaging to properly evaluate shoulder scar tissue:

1. Inspection and Palpation 1, 3

   • Observe shoulder contour and muscle atrophy
   • Palpate key tender points:
     • Long head of biceps brachii (most common tender point)
     • Pectoralis minor
     • Lateral intermuscular septum
     • Proximal tendons of extensor group

2. Range of Motion Assessment 1

   • Active and passive motion in all planes:
     • Forward flexion
     • Abduction
     • External rotation
     • Internal rotation
   • Note pain arcs and limitations
   • Compare with contralateral side

3. Strength Testing 1

   • Evaluate rotator cuff muscles (supraspinatus, infraspinatus/teres minor, subscapularis)
   • Test deltoid and biceps strength
   • Grade on 0-5 scale

Evaluation Based on Suspected Pathology

For Labral Tears with Scar Tissue

• MR arthrography is the preferred imaging modality (rated 9/9) 2
• Especially recommended for patients under 35 years of age 1

For Rotator Cuff Pathology with Scar Tissue

• MRI without contrast (rated 7/9) or ultrasound (rated 9/9) if local expertise is available 2
• Both MRI and ultrasound are equivalent for evaluating bursitis or biceps tenosynovitis 2

For Post-Arthroplasty Scar Tissue

• Begin with radiographs to assess hardware components and alignment 2
• Follow with CT or MRI based on initial findings 2
• Nuclear medicine studies (bone scans) can help differentiate between normal post-operative changes and complications 2

Common Pitfalls and Caveats

1. Overreliance on a single imaging modality

   • A multimodal approach may be required to accurately assess shoulder pathology 2
   • Different imaging techniques have complementary roles

2. Neglecting physical examination

   • Even with technological advances, palpation remains a cost and time-efficient tool 3
   • Tender point distribution varies depending on the underlying pathology 3

3. Misinterpreting post-surgical changes

   • Normal post-operative bone remodeling can mimic pathology on imaging 2
   • Serial imaging may be necessary to differentiate normal healing from complications

4. Failing to correlate clinical findings with imaging

   • Successful treatment requires accurate correlation between physical examination and imaging findings 4
   • Some scar tissue may be symptomatic but not visible on standard imaging

By following this systematic approach to evaluating shoulder scar tissue, clinicians can accurately diagnose the underlying pathology and develop appropriate treatment strategies to improve patient outcomes.