Shoulder pain is one of the most common musculoskeletal problems we see at Axis. Many patients arrived convinced they have "torn their rotator cuff" because they have "had a scan". Many of these patients come worried that they need surgery, sometimes with only modest symptoms.

While imaging is clearly important, it is easy for both patient's history, examination and overall presentation. This can lead to unnecessary anxiety, inappropriate treatment and, in some cases, surgery that may not be needed.

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Not every scan finding explains the pain

Ultrasound scans are excellent at showing the structure of the shoulder, but they do not always identify the source of a person's pain. Rotator cuff abnormalities are a good example.

Studies have shown that tendon changes are surprisingly common, even in people who have no shoulder pain. Partial tears and other tendon changes can be found in younger adults, while full thickness tears become increasingly common with age. Around one in five adults in their 60s has a full-thickness rotator cuff tear despite having little or no pain.

These findings highlight an important principle; these changes are normal for some people and not everything seen on a scan is responsible for a person's symptoms.

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Why clinical assessment matters

In our experience shoulder pain in those over 40 years is mostly commonly cause by rotator cuff disease, acromioclavicular joint dysfunction or adhesive capsulitis (frozen shoulder).

These conditions frequently overlap and often present with remarkably similar symptoms. All can disturb sleep, make reaching overhead difficult and limit day-to-day activities.

Distinguishing between them from a patient's referral or scan alone can be challenging, which is why a careful history and physical examination remain the cornerstone of diagnosis.

Understanding how symptoms began is important. Many people assume that because shoulder pain started after an incideny, it is automatically covered by ACC.

In reality, clinicians must determine whether there is a plausible causal link between the injury and the condition being treated. Was the injury significant enough to cause the pathology seen on examination and imaging, or has it simply brought to light changes that were already present and not previously causing symptoms.

The question is complex and is important for ACC entitlement, but it is even more important for patients and clinicians becuase it diectly influences treatment decisions and expected outcomes.

An acute traumatic rotator cuff tear in a previously healthy tendon may require early surgical repair, while many longer-standing tendon tears and frozen shoulder are almost always managed non-surgically.

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Choosing the right treatment

The good news is that most people improve. Many patients with full-thickness rotator cuff tears achieve excellent outcomes with education and progressive rehabilitation.

For patients whose pain is limiting their rehabilitation, a carefully selected corticosteroid injection can also be a effective treatment. At our dedicated Shoulder Clinic, we assess whether an injection is appropriate and, when indicated, can often perform an ultrasound-guided injection as part of the same episode of care.

Choosing the right treatment starts with choosing the right diagnosis. The decision is rarely about whether a tear exists. It is about whether that teaR is responsible for the patient's symptoms.

When shoulder pain persists, the most important question is often not, "What does the scan show?" but "What is actually causing the pain?"

Answering that question is usually the key to helping patients recover and return to the activities they enjoy.