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Find the Correct Shoulder Injury Diagnosis

Shoulder pain – This can be difficult at all levels including professional athletes- highlighted with the recent episode involving professional pitcher Stephen Strasburg. For overhead sports like baseball, the margin of error can be very small and a benign appearing shoulder pain can quickly become a career ending injury.

Nerves are ultimately responsible for signaling pain and the shoulder is surrounded by a shoulder-injuryrich network of nerves– many are on their way to other sites in the body- sometimes pain or injury in one area of the body is actually felt in another area. This is sometimes called referred pain. Some common sources of referred shoulder pain include but are not limited to pain or disease in the gallbladder, liver, lung, diaphragm, heart, and neck (cervical spine). Some diseases-like diabetes- that cause neuropathy or alter the body’s ability to feel pain can also increase the risk for shoulder surgery problems. Injury, overuse, arthritis, and genetics along with routine wear and tear can also play an important role in shoulder pain. One of the most common nerves often overlooked as a source of pain and disability is the suprascapular nerve. Here are two sources for more information on diagnosis and treatment of suprascapular nerve pathology.

Shoulder Pain Causes

With so many possible causes for shoulder pain, it is important to first determine what is responsible for your pain before jumping ahead with potentially unnecessary, expensive, and sometimes dangerous treatment.  For me, this always starts with a thorough history and examination, which I find to be the most important diagnostic tools even though with all the advancements in modern medicine, it has become more common to rely on diagnostic tests.

Combining Techniques

Even though no one physical examination technique by itself is wholly reliable, I find the combination of multiple techniques combined with clinical judgment are invaluable in guiding the confirmatory diagnostic tests I order.  In other words, successful treatment starts with first establishing the correct diagnosis.

A Working Diagnosis

Once a working diagnosis is formulated, the appropriate confirmatory diagnostic tests are ordered.  Many patients request an MRI for shoulder pain-one of the problems with just ordering an MRI of the shoulder is that the diagnostic accuracy of an MRI is highly variable depending on the diagnosis. Here is more information regarding MRI for shoulder pain.

Rotator Cuff Tears

Especially for rotator cuff tears deep in the shoulder an MRI arthrogram is more accurate. Because no diagnostic test is perfect, it is not unusual to have a patient come in with a diagnostic test with a report positive for some sort of tear, but upon performing the history and examination the patient has a completely different cause for the shoulder pain and the diagnostic test results are an incidental asymptomatic finding.

Clinical Correlations

The opposite scenario is also common-the history and examination are strongly positive for pathology in a particular region, but the diagnostic report is normal. I always review diagnostic images and tests personally because having the benefit of clinical correlation often indicates pathology on the diagnostic test that would not have been picked up otherwise. Rotator cuff tears, for example, are a common cause of shoulder pain, but the MRI appearance and diagnostic accuracy for rotator cuff tears can vary for multiple reasons.


Pain changes our ability to remain objective and it is common for patients to proceed with treatments in an effort to resolve the pain without first having a clearly established diagnosis. As frustrating as shoulder pain can be, we recommend taking the time to establish the correct diagnosis first in order to avoid a failed shoulder surgery.
In summary, if your shoulder pain has persisted despite rest and simple common treatments, we highly recommend you discuss the matter with your shoulder specialist to start the process of getting you a firm diagnosis and ultimately a solution for your shoulder pain.

Vivek Agrawal, MD

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