Should an MRI be ordered to rule out a tear in the left shoulder?

MRI for Suspected Left Shoulder Tear

An MRI is not indicated at this time for a patient who can perform activities of daily living without limitations and has only a dull ache in the shoulder, despite the patient's request. 1, 2

Clinical Assessment and Imaging Decision-Making

The patient presents with:

• Dull ache in the left shoulder
• Full range of motion compared to the right side
• Ability to complete activities of daily living without limitations
• Daily stretching and exercise routine
• Patient belief that there is a tear requiring MRI

When MRI is Appropriate for Shoulder Pain

According to the American College of Radiology (ACR) Appropriateness Criteria, advanced imaging should be reserved for specific clinical scenarios:

• MRI shoulder without IV contrast is appropriate when:
  • Physical examination is consistent with rotator cuff tear AND there are functional limitations 1
  • There is no improvement after appropriate conservative management 2
  • There are strength deficits on examination 3

Why MRI is Not Indicated in This Case

1. Functional Status: The patient can complete activities of daily living without limitations 1, 3
2. Range of Motion: The patient reports full range of motion compared to the unaffected side 2
3. Conservative Management: There is no indication that conservative management has been exhausted 3

Appropriate Management Approach

First-Line Management

• Conservative management is the recommended first-line approach for shoulder pain without significant functional limitations 2
• This includes:
  • NSAIDs for pain control
  • Activity modification to avoid painful movements
  • Ice, heat, and soft tissue massage for symptomatic relief
  • Progressive rehabilitation exercises

Follow-up and Monitoring

• Initial follow-up should occur in 1-2 weeks to assess response to treatment 2
• Clinical reassessment at 6 weeks to evaluate progress 2
• Consider imaging or surgical consultation if:
  • Symptoms worsen
  • No improvement after 3 months of appropriate rehabilitation
  • Development of functional limitations or strength deficits 2

Value-Based Care Considerations

MRI ordered before a trial of conservative management in patients with atraumatic shoulder pain and minimal functional deficits provides negative value in patient management 3:

• Studies show that over 90% of such patients do not require surgical intervention
• Primary care-ordered MRIs influence clinical management in less than 25% of cases 4

When to Reconsider MRI

MRI should be reconsidered if:

• Patient develops strength deficits on examination
• Functional limitations in activities of daily living emerge
• No improvement after 3 months of appropriate conservative management
• Development of mechanical symptoms (catching, locking)

While MRI has excellent sensitivity (91%) for detecting rotator cuff tears 5, ordering this test prematurely when it will not change management represents low-value care and unnecessary healthcare expenditure.