Shoulder MRI Interpretation and Treatment Recommendations
MRI Interpretation
Your patient has mild glenohumeral and acromioclavicular joint osteoarthritis with minimal subacromial-subdeltoid bursitis, but importantly, no rotator cuff tear. This is a favorable finding that allows for conservative management without surgical referral at this time 1.
Key Findings:
- Intact rotator cuff: No tendon tears or significant tendinopathy—this is the most important prognostic factor 1
- Mild osteoarthritis: Affects both the glenohumeral and AC joints, but not severe 1
- Minimal bursitis: Subacromial-subdeltoid inflammation is present but not extensive 1
- No mechanical complications: No loose bodies, fractures, or aggressive lesions requiring urgent intervention 1
Treatment Algorithm
First-Line Core Treatments (Start Here for Every Patient)
1. Exercise and Physical Therapy 1, 2
- Strengthening exercises for rotator cuff and scapular stabilizers
- Range of motion exercises to prevent stiffness
- Low-impact aerobic activities
- Aim for at least 30 minutes most days of the week 2
2. Weight Management (if applicable) 1, 2
- Even 5-10% body weight loss significantly reduces joint pain in overweight patients 2
3. Local Heat Application 1, 2
Second-Line Pharmacological Treatment
4. Paracetamol (Acetaminophen) First 1, 2
- Up to 4 grams daily in divided doses
- This is the preferred first-line oral analgesic due to safety profile 1
- Regular dosing may be more effective than as-needed 1
- Consider before oral NSAIDs for localized pain
- Effective with minimal systemic exposure 1
6. Oral NSAIDs (if paracetamol insufficient) 1, 2, 3
- Use at the lowest effective dose for the shortest duration 1, 2
- Prescribe with a proton pump inhibitor for gastroprotection 1
- Monitor for gastrointestinal, cardiovascular, and renal toxicity, especially in elderly patients 1, 3
- Ibuprofen has been shown to cause less gastric irritation than aspirin at comparable doses 3
Third-Line Interventional Options
7. Intra-articular Corticosteroid Injection 1
- Consider for moderate to severe pain flares 1
- Particularly effective for glenohumeral osteoarthritis 1
- Can provide relief for over 3 months in some patients 4
- Important caveat: Evidence specifically for glenohumeral OA is limited (Grade I recommendation), though widely used in clinical practice 1
8. Viscosupplementation (Hyaluronic Acid Injection) 1
- This is an option for glenohumeral OA when other treatments fail 1
- Evidence is limited but shows improvement in pain scores at 1,3, and 6 months 1
- Consider as an alternative to corticosteroid injection 1
When to Refer to Orthopedics
Do NOT refer at this time unless conservative treatment fails after an adequate trial (typically 3-6 months) 1. Referral criteria include:
- Pain and functional limitation that substantially affect quality of life despite comprehensive conservative treatment 1
- Progressive symptoms despite adherence to therapy 1
- Development of mechanical symptoms (locking, catching) 1
- Patient preference for surgical evaluation after failed conservative care 1
Note: Arthroscopic debridement has insufficient evidence for glenohumeral OA and should not be routinely considered 1. Joint replacement is reserved for severe, refractory cases 1.
Critical Pitfalls to Avoid
- Do not skip core treatments: Exercise and weight management must be offered before considering surgery 1
- Avoid prolonged NSAID use: Monitor renal function, especially in elderly patients 1, 2
- Do not use glucosamine or chondroitin: These are not recommended due to lack of evidence 1
- Avoid premature surgical referral: Ensure at least 3-6 months of guideline-concordant conservative therapy first 1