Shoulder pain: to image or not to image?

Le résumé fourni par la source

1. INTRODUCTION Imaging findings should be interpreted within the broader context of an individual's shoulder symptoms (1). While imaging is valuable in identifying specific structural pathologies, findings are often equivocal. Defining what imaging changes constitute "normal", "abnormal", "unrelated", "solely causative" findings, and which are, "contributory", or "associated" with symptoms is a clinical minefield. Although a naive interpretation might equate "normal" with the absence of pathological features (e.g., no rotator cuff tears, calcification, or labral lesions), this is an oversimplification. For example, rotator cuff tendon tears are frequently observed in individuals without symptoms, who function for years at a very high level of performance. Rotator cuff tendon tears increase asymptomatically with increasing age, suggesting, like wrinkles and grey hair, the tears are likely to be a normal non-noxious senescent change (2). Furthermore, individuals may exhibit full mobility, exceptional muscle performance, no symptoms, and above average function despite observable labral tears, tendon irregularities commonly termed tendinosis, or partial/full-thickness rotator cuff tears (3-7). Moreover, non-sinister and non-traumatic soft tissue imaging considered to be abnormal cannot reliably distinguish currently symptomatic shoulders, previously symptomatic, or those that have never been symptomatic, as the prevalence of "abnormal" findings is often similar across these groups (3, 8, 9). It is arguable that many so called "abnormalities" have been labeled as such because they represent deviations in structure from idealized and flawless anatomical drawings. The equivocal association between imaging changes and symptoms has lead researchers and clinicians, to question a biomechanical role in symptom causation and/or perpetuation. This is evident in the arguments such as nociception is not needed to experience pain (10), and that pain should be considered a perception and not a sensation (11). These arguments, commonplace in pain science, are not supported by definitive research and should still be regarding as hypotheses and not "fait accompli". Without doubt, psychosocial factors and the social determinants of health play a seismic role in the experience, perpetuation, and prognosis of symptoms for those living with shoulder pain (12, 13). However, arguments have been made to reframe the relevance of 'bio' in shoulder symptoms, and recently a strong case has been made to consider bio-chemical factors in the development and perpetuation of rotator cuff related shoulder pain (14). The appropriate utilization and necessity of shoulder imaging is also equivocal. Guidelines offer inconsistent recommendations and conflicting advice concerning the prescription of radiographs for diagnosing rotator cuff tendinopathy, as some guidelines recommend radiographs during the initial evaluation (e.g., routinely), although others suggest that radiographs might be considered, especially when conservative treatment fails (15). Notably, one high-quality guideline did not recommend radiographs for the initial management (15). Lastly, International Consensus suggests using certain dynamic imaging techniques as complementary to medical history and physical examination for the clinical assessment of dysfunctional disorders (e.g., subluxation, instability). This approach could aid clinicians in perceiving "functional" disorders rather than solely anatomical or structural injuries (16). As a consequence of this ambiguity, a significant number of clinicians were responsible for referrals for "low-value" imaging, especially for those without a traumatic onset (17). To promote consideration for the role of "bio" in shoulder symptoms and encourage debate among clinicians and researchers, this opinion paper aims to stimulate discussion on the value of imaging in management of musculoskeletal shoulder pain. We sought to capture diverse perspectives from various health disciplines by incorporating input from clinicians, researchers, educators, physiotherapists, physicians, and nurses working within the musculoskeletal field, aimed at providing a comprehensive perspective to our manuscript. 2. PROS AND CONS OF IMAGING USE IN SHOULDER PAIN MANAGEMENT Although the judicious requests of imaging may improve clinician understanding of a specific clinical scenario, between 20–50% of imaging requests are inappropriate or of "low-value" (e.g., a service offering no or minimal benefit to patients). Primum non nocere (first, do no harm) is a core principal in healthcare practice. Unnecessary imaging has the potential to cause harm (e.g. unnecessary risk due to exposure to ionizing radiation) (18), prolong waiting times, and further negatively impact of spiraling healthcare costs (17). Conversely, strategies aimed at reducing low-value imaging have the potential to decrease costs by as much as 95% without compromising patient well-being (17). How patients interpret the imaging report findings will influence their beliefs about appropriate management, (e.g. "I have a tear, I need surgery") (19). When writing an imaging report, pathoanatomical labelling without reference to the incidence and prevalence of findings in people without symptoms could lead to "medical overuse" as unnecessary injections, surgical and nonsurgical procedures (20), as well as healthcare-seeking behavior reinforcing maladaptive beliefs about damage (21). A further concern in the interpretation of shoulder imaging is the observed fair to moderate inter-rater agreement among different examiners when reporting on identical scans (9, 22), a factor that is also influenced by the experience of the individual professional and which can potentially result in patient disorientation, unhelpful guidance, and unwarranted subsequent investigations (23). Studies investigating this issue, question the clinical utility of routine imaging for treatment planning, given the high prevalence of anatomical variations in asymptomatic shoulders (1, 8, 9, 24). Indeed, while imaging may identify tissue pathology, it often cannot reliably determine the clinical significance of these findings or their correlation with specific symptoms. For instance, routine plain radiographs in individuals with atraumatic shoulder pain altered the diagnosis based on medical history and physical examination in fewer than 15% of cases, and clinical management was modified in only 1.7% of cases (25). Furthermore, in individuals with frozen shoulder, additional pathologies were identified via magnetic resonance imaging in 22% of subjects. However, a modification in the treatment plan based on these findings was observed in only 2.7% of cases, and 37 resonance scans were required to identify one patient with frozen shoulder necessitating surgery due to the additional imaging findings (26). In conclusion, acceptance of imaging findings (i) without defining what abnormal is based upon and (ii) without stating the prevalence of such findings in people without symptoms, may lead to over medicalization and detrimentally impact on healthcare sustainability. Getting the balance right The thoughtful application of imaging strategies may confer several advantages. Firstly, imaging may identify relevant structural pathologies when serious pathology is a primary concern (27). In complex, traumatic, or suspicious cases, where differential diagnosis is challenging due to the overlap of clinical signs and symptoms, the selection of the appropriate imaging modality may help prevent delays in management (28). Moreover, imaging may corroborate structural healing following surgical intervention. For instance, in rotator cuff repair, an ultrasound scan or magnetic resonance imaging can confirm the secure placement of bone anchors, demonstrating the technical success of the surgery. Although importantly, from a clinical standpoint, tendon to tendon, and tendon to bone healing is not a pr

Ce résumé expose les affirmations des auteurs. BNTIC ne l’interprète pas comme une validation indépendante des résultats.