Fabrizio Brindisino1*
Paul Salamh2,3
Chad Cook4,5,6
Jeremy Lewis7,8,9,10
Alvisa Palese11
Germano Guerra1Jacopo Bonavita12
Giacomo Rossettini13,14
- 1Department of Medicine and Health Science “Vincenzo Tiberio”, University of Molise, Campobasso, Italy
- 2Krannert School of Physical Therapy, University of Indianapolis, Indianapolis, IN, United States
- 3Department of Rehabilitation Sciences, Tufts School of Medicine, Boston, MA, United States
- 4Department of Orthopaedic Surgery, Duke University, Durham, NC, United States
- 5Duke Clinical Research Institute, Duke University, Durham, NC, United States
- 6Department of Population Health Sciences, Duke University, Durham, NC, United States
- 7Therapy Department, Central London Community Healthcare National Health Service Trust, Finchley Memorial Hospital, London, United Kingdom
- 8School of Health Sciences, University of Nottingham, Nottingham, United Kingdom
- 9School of Life and Health Sciences, University of Nicosia, Nicosia, Cyprus
- 10School of Allied Health, University of Limerick, Limerick, Ireland
- 11Department of Medical Sciences, University of Udine, Udine, Italy
- 12Neurorehabilitation Unit, Villa Rosa Hospital, APSS Trento, Trento, Italy
- 13School of Physiotherapy, University of Verona, Verona, Italy
- 14Department of Physiotherapy, Faculty of Medicine, Health and Sports, Universidad Europea de Madrid, Madrid, Spain
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 non-surgical 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.
2.1 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 prerequisite for a reduction in pain and improvement in function after repair (29, 30).
When indicated based on a suspicion of clinically significant structural failure, imaging will be invaluable for a detailed assessment of tissue biology (e.g., a bony Bankart lesion following trauma-related anterior shoulder instability). This information will guide targeted and shared treatment decisions and facilitate specialist involvement (e.g., surgical consultation) as necessary, promoting a positive multidisciplinary approach involving specialists capable of accurate, evidence-based interpretation of structural details.
Lastly, in cases where non-surgical management does not result in the expected clinical improvement, the contribution of traumatically and non-traumatically acquired structural variations warrants evaluation, facilitated by the wise selection of imaging for changing the path of care (27). In Table 1, we presented scenarios taken from everyday clinical practice to stimulate discussion on pro- and cons- for imaging use in shoulder pain management, while Supplementary Figure S1 (Supplementary Material), details a SWOT -strength, weaknesses, opportunities, and threat- analysis for the use of imaging in shoulder pain management. Lastly, we have included a clinical decision-making diagram (Supplementary Figure S2, Supplementary Material) to illustrate the authors' proposed method for integrating clinical and imaging findings. This diagram is designed to simplify the decision-making process for determining when imaging is necessary, unnecessary, or a borderline case.
Table 1. Clinical practice scenarios to stimulate discussion on pro- and cons- for imaging use in shoulder pain management.
3 Implications
Prior to, or during attendance at out-patient shoulder orthopedic clinics routine imaging (usually radiographs) is common practice. This may help identify rare conditions requiring urgent management, such as osteosarcomas. However, in-depth interview practice and appropriate safety netting would reduce the need for blanket imaging and lessen the potential harms associated with being informed of tendon and/or bone changes that may, and equally may not be associated with symptoms and in the main will respond equally well to non-surgical management.
“Low-value” imaging equates to billions of dollars of wasted resources. For example, within magnetic resonance imaging, a primary cohort receiving imaging referrals discordant with guidelines included orthopedic patients and patients referred by general practitioners (17, 31). Additionally, atraumatic pain was identified as a specific clinical condition where the use of “low-value” imaging was particularly evident (17). Measures for reducing “low-value” imaging and to promote reasonable use and recommendation of it are needed at all levels of healthcare, for promoting interprofessional collaboration and networking, thereby improving patient care and perceived support by the patient.
Clinical guidelines recommend judicious use of imaging in people with shoulder pain, discouraging routine imaging, but fully utilize their use in probable red flag presentations (27, 32). Imaging should also be considered in non-improving (possibly at 12 weeks), or earlier, with worsening symptoms (27, 32). The appropriate utilization of imaging for a comprehensive understanding of clinical scenarios holds significant implications for both clinical practice and research. Clinicians (e.g., physicians, chiropractors, physiotherapists) bear the responsibility to justify the need to image and if a decision to image is made, determine the appropriate timing and type of imaging studies. This must be done within a shared decision making framework, and to recognize when multidisciplinary consultation is necessary to address patient needs effectively (33).
Shared decision making requires consideration of the benefits and potential harms of imaging. It needs to be framed within comprehensive patient education, encompassing the current clinical status and patient wishes for management. For example, in the absence of red flag concerns is imaging necessary for a patient who wishes to focus on non-invasive, non-surgical management (34)?
This opinion paper aims to stimulate a mature, balanced discourse that empowers less experienced clinicians to make informed decisions with individual patients, considering all pertinent factors contributing to their well-being. Within a proper application of the bio-psycho-social model of care, biological variables must be acknowledged, and in-depth analysis through imaging modalities can serve as a valuable strategy. As showed in the six clinical cases in Table 1, people presenting with painful shoulder conditions, particularly when specific anamnesis and predisposing factors were present, imaging may:
• Confirm the presence of structural abnormalities requiring multidisciplinary consultation [e.g., expert opinion(s)].
• Guide clinicians towards targeted interventions addressing specific structural pathologies, thereby enhancing treatment efficacy (e.g., calcific tendinopathy).
• Prevent adverse outcomes resulting from misdiagnosed conditions (e.g., instability with rotator cuff tear).
• Facilitate accurate differential diagnosis, mitigating the risk of overlooking clinically significant comorbidities (e.g., frozen shoulder).
4 Conclusion
Clinical practice frequently lacks balance and frequently is conducted at the ends of a spectrum. With one end being rigid reliance on structural imaging and the other its rejection in favor of a psychosocial narrative. Yet clinical reality is rarely binary, and practicing at the end of any spectrum, as is in most situations in life, leads to cognitive distortion, and blind adherence to one belief over another. Recent medical examples include the discourse on vaccination, and in physiotherapy, the -often- toxic debate relating to touch therapy. The Latin phrase, in medias res (the solution lies in the middle) is very apt.
To promote a judicious, resourceful, and evidence-based utilization of imaging, research should emphasize a comprehensive bio-psycho-social care pathway. Within this framework, all relevant domains should be engaged and weighted according to the specific clinical context.
Educational curricula for all health professions should incorporate formative modules designed to enhance expertise in imaging strategies, including their clinical applicability and utility, strengths and limitations, and potential benefits and drawbacks. Moreover, receiving individualized written audit and feedback on imaging request rates —including the benefits of addressing imaging overuse, links to educational resources, and guidance on limiting imaging requests— could significantly decreased overall rate of musculoskeletal imaging requests (35–37), and could be a widely strategy for enhancing professional practice.
A balanced, context-driven use of imaging, grounded in clinical reasoning and embedded in a biopsychosocial model, can enhance diagnosis, inform treatment, and support shared decision-making. Imaging is a valuable tool when used wisely: the question is not whether to use it, but when, why, and for whom.
Author contributions
FB: Methodology, Conceptualization, Writing – original draft. PS: Supervision, Methodology, Writing – original draft, Validation. CC: Supervision, Writing – original draft, Methodology, Validation. JL: Writing – original draft, Methodology, Supervision, Validation. AP: Validation, Methodology, Supervision, Writing – original draft. GG: Validation, Methodology, Supervision, Writing – original draft. JB: Writing – original draft, Supervision, Validation. GR: Validation, Conceptualization, Supervision, Methodology, Writing – original draft.
Funding
The author(s) declare that no financial support was received for the research and/or publication of this article.
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
The author(s) declared that they were an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision.
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Supplementary material
The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fresc.2025.1624056/full#supplementary-material
References
1. Tran G, Cowling P, Smith T, Bury J, Lucas A, Barr A, et al. What imaging-detected pathologies are associated with shoulder symptoms and their persistence? A systematic literature review. Arthritis Care Res (Hoboken). (2018) 70(8):1169–84. doi: 10.1002/acr.23554
2. Yamamoto A, Takagishi K, Osawa T, Yanagawa T, Nakajima D, Shitara H, et al. Prevalence and risk factors of a rotator cuff tear in the general population. J Shoulder Elbow Surg. (2010) 19(1):116–20. doi: 10.1016/j.jse.2009.04.006
3. Ibounig T, Sanders S, Haas R, Jones M, Järvinen TL, Taimela S, et al. Systematic review of shoulder imaging abnormalities in asymptomatic adult shoulders (SCRUTINY): abnormalities of the glenohumeral joint. Osteoarthr Cartil. (2024) 32(10):1184–96. doi: 10.1016/j.joca.2024.06.001
4. Miniaci A, Mascia AT, Salonen DC, Becker EJ. Magnetic resonance imaging of the shoulder in asymptomatic professional baseball pitchers. Am J Sports Med. (2002) 30(1):66–73. doi: 10.1177/03635465020300012501
5. Connor PM, Banks DM, Tyson AB, Coumas JS, D'Alessandro DF. Magnetic resonance imaging of the asymptomatic shoulder of overhead athletes:a 5-year follow-up study. Am J Sports Med. (2003) 31(5):724–7. doi: 10.1177/03635465030310051501
6. Del Grande F, Aro M, Jalali Farahani S, Cosgarea A, Wilckens J, Carrino JA. High-resolution 3-T magnetic resonance imaging of the shoulder in nonsymptomatic professional baseball pitcher draft picks. J Comput Assist Tomogr. (2016) 40(1):118–25. doi: 10.1097/RCT.0000000000000327
7. Pennock AT, Dwek J, Levy E, Stearns P, Manning J, Dennis MM, et al. Shoulder MRI abnormalities in asymptomatic little league baseball players. Orthop J Sports Med. (2018) 6(2):2325967118756825. doi: 10.1177/2325967118756825
8. Gill TK, Shanahan EM, Allison D, Alcorn D, Hill CL. Prevalence of abnormalities on shoulder MRI in symptomatic and asymptomatic older adults. Int J Rheum Dis. (2014) 17(8):863–71. doi: 10.1111/1756-185X.12476
9. Barreto RPG, Braman JP, Ludewig PM, Ribeiro LP, Camargo PR. Bilateral magnetic resonance imaging findings in individuals with unilateral shoulder pain. J Shoulder Elbow Surg. (2019) 28(9):1699–706. doi: 10.1016/j.jse.2019.04.001
10. Baliki Marwan N, Apkarian AV. Nociception, pain, negative moods, and behavior selection. Neuron. (2015) 87(3):474–91. doi: 10.1016/j.neuron.2015.06.005
11. Higinio-Rodríguez F, Rivera-Villaseñor A, Calero-Vargas I, López-Hidalgo M. From nociception to pain perception, possible implications of astrocytes. Front Cell Neurosci. (2022) 16:972827. doi: 10.3389/fncel.2022.972827
12. Chester R, Jerosch-Herold C, Lewis J, Shepstone L. Psychological factors are associated with the outcome of physiotherapy for people with shoulder pain: a multicentre longitudinal cohort study. Br J Sports Med. (2018) 52(4):269–75. doi: 10.1136/bjsports-2016-096084
13. De Baets L, Matheve T, Meeus M, Struyf F, Timmermans A. The influence of cognitions, emotions and behavioral factors on treatment outcomes in musculoskeletal shoulder pain: a systematic review. Clin Rehabil. (2019) 33(6):980–91. doi: 10.1177/0269215519831056
14. Lo CN, Leung BPL, Sanders G, Li MWM, Ngai SPC. The major pain source of rotator cuff-related shoulder pain: a narrative review on current evidence. Musculoskeletal Care. (2023) 21(2):285–93. doi: 10.1002/msc.1719
15. Lowry V, Lavigne P, Zidarov D, Matifat E, Cormier AA, Desmeules F. A systematic review of clinical practice guidelines on the diagnosis and management of various shoulder disorders. Arch Phys Med Rehabil. (2024) 105(2):411–26. doi: 10.1016/j.apmr.2023.09.022
16. Ricci V, Chang KV, Güvener O, Mezian K, Kara M, Leblebicioğlu G, et al. EURO-MUSCULUS/USPRM dynamic ultrasound protocols for shoulder. Am J Phys Med Rehabil. (2022) 101(3):e29–36. doi: 10.1097/PHM.0000000000001833
17. Kjelle E, Brandsæter IØ, Andersen ER, Hofmann BM. Cost of low-value imaging worldwide: a systematic review. Appl Health Econ Health Policy. (2024) 22(4):485–501. doi: 10.1007/s40258-024-00876-2
18. Ingraham B, Miller K, Iaia A, Sneider MB, Naqvi S, Evans K, et al. Reductions in high-end imaging utilization with radiology review and consultation. J Am Coll Radiol. (2016) 13(9):1079–82. doi: 10.1016/j.jacr.2016.04.016
19. Zadro JR, O'Keeffe M, Ferreira GE, Haas R, Harris IA, Buchbinder R, et al. Diagnostic labels for rotator cuff disease can increase people’s perceived need for shoulder surgery: an online randomized controlled trial. J Orthop Sports Phys Ther. (2021) 51(8):401–11. doi: 10.2519/jospt.2021.10375
20. Helms J, Frankart L, Bradner M, Ebersole J, Regan B, Crouch T. Interprofessional active learning for chronic pain: transforming student learning from recall to application. J Med Educ Curric Dev. (2023) 10:23821205231221950. doi: 10.1177/23821205231221950
21. Smythe A, Rathi S, Pavlova N, Littlewood C, Connell D, Haines T, et al. Self-reported management among people with rotator cuff related shoulder pain: an observational study. Musculoskeletal Sci Pract. (2021) 51:102305. doi: 10.1016/j.msksp.2020.102305
22. van Grinsven S, Nijenhuis TA, Konings PC, van Kampen A, van Loon CJ. Are radiologists superior to orthopaedic surgeons in diagnosing instability-related shoulder lesions on magnetic resonance arthrography? A multicenter reproducibility and accuracy study. J Shoulder Elbow Surg. (2015) 24(9):1405–12. doi: 10.1016/j.jse.2015.05.050
23. Lluch-Girbés E, Dueñas L, Struyf F, Camerone EM, Rossettini G. Negative expectations and related nocebo effects in shoulder pain: a perspective for clinicians and researchers. Pain Manag. (2025) 15(2):93–104. doi: 10.1080/17581869.2025.2467022
24. Cortes A, Quinlan NJ, Nazal MR, Upadhyaya S, Alpaugh K, Martin SD. A value-based care analysis of magnetic resonance imaging in patients with suspected rotator cuff tendinopathy and the implicated role of conservative management. J Shoulder Elbow Surg. (2019) 28(11):2153–60. doi: 10.1016/j.jse.2019.04.003
25. Feder OI, Levy BJ, Gruson KI. Routine plain radiographs in the setting of atraumatic shoulder pain: are they useful? J Am Acad Orthop Surg. (2018) 26(8):287–93. doi: 10.5435/JAAOS-D-16-00884
26. Dimitriou D, Winkler E, Zindel C, Grubhofer F, Wieser K, Bouaicha S. Is routine magnetic resonance imaging necessary in patients with clinically diagnosed frozen shoulder? Utility of magnetic resonance imaging in frozen shoulder. JSES Int. (2022) 6(5):855–8. doi: 10.1016/j.jseint.2022.05.009
27. Desmeules F, Roy J-S, Lafrance S, Charron M, Dubé M-O, Dupuis F, et al. Rotator cuff tendinopathy diagnosis, nonsurgical medical care, and rehabilitation: a clinical practice guideline. J Orthop Sports Phys Ther. (2025) 55(4):235–74. doi: 10.2519/jospt.2025.13182
28. Goodman CC. Screening for gastrointestinal, hepatic/biliary, and renal/urologic disease. J Hand Ther. (2010) 23(2):140–57. doi: 10.1016/j.jht.2009.10.005
29. Russell RD, Knight JR, Mulligan E, Khazzam MS. Structural integrity after rotator cuff repair does not correlate with patient function and pain: a meta-analysis. J Bone Joint Surg Am Vol. (2014) 96(4):265–71. doi: 10.2106/JBJS.M.00265
30. Elliott RSJ, Lim YJ, Coghlan J, Troupis J, Bell S. Structural integrity of rotator cuff at 16 years following repair: good long-term outcomes despite recurrent tears. Shoulder Elbow. (2019) 11(1):26–34. doi: 10.1177/1758573217738198
31. Müskens J, Kool RB, van Dulmen SA, Westert GP. Overuse of diagnostic testing in healthcare: a systematic review. BMJ Qual Saf. (2022) 31(1):54–63. doi: 10.1136/bmjqs-2020-012576
32. Lin I, Wiles L, Waller R, Goucke R, Nagree Y, Gibberd M, et al. What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review. Br J Sports Med. (2020) 54(2):79–86. doi: 10.1136/bjsports-2018-099878
33. Boissonnault W, Goodman C. Physical therapists as diagnosticians: drawing the line on diagnosing pathology. J Orthop Sports Phys Ther. (2006) 36(6):351–3. doi: 10.2519/jospt.2006.0107
34. Hoffmann T, Jansen J, Glasziou P. The importance and challenges of shared decision making in older people with multimorbidity. PLoS Med. (2018) 15(3):e1002530. doi: 10.1371/journal.pmed.1002530
35. O'Connor DA, Glasziou P, Maher CG, McCaffery KJ, Schram D, Maguire B, et al. Effect of an individualized audit and feedback intervention on rates of musculoskeletal diagnostic imaging requests by Australian general practitioners: a randomized clinical trial. Jama. (2022) 328(9):850–60. doi: 10.1001/jama.2022.14587
36. Schectman JM, Schroth WS, Verme D, Voss JD. Randomized controlled trial of education and feedback for implementation of guidelines for acute low back pain. J Gen Intern Med. (2003) 18(10):773–80. doi: 10.1046/j.1525-1497.2003.10205.x
37. Winkens RA, Pop P, Bugter-Maessen AM, Grol RP, Kester AD, Beusmans GH, et al. Randomised controlled trial of routine individual feedback to improve rationality and reduce numbers of test requests. Lancet. (1995) 345(8948):498–502. doi: 10.1016/S0140-6736(95)90588-X
38. Goodman CC. Screening for medical problems in patients with upper extremity signs and symptoms. J Hand Ther. (2010) 23(2):105–25. doi: 10.1016/j.jht.2009.09.005
39. Finucane LM, Downie A, Mercer C, Greenhalgh SM, Boissonnault WG, Pool-Goudzwaard AL, et al. International framework for red flags for potential serious spinal pathologies. J Orthop Sports Phys Ther. (2020) 50(7):350–72. doi: 10.2519/jospt.2020.9971
40. Lollino N, Brunocilla PR, Poglio F, Vannini E, Lollino S, Lancia M. Non-orthopaedic causes of shoulder pain: what the shoulder expert must remember. Musculoskelet Surg. (2012) 96(Suppl 1):S63–8. doi: 10.1007/s12306-012-0192-5
41. Pennella D, Giagio S, Maselli F, Giovannico G, Roncone A, Fiorentino F, et al. Red flags useful to screen for gastrointestinal and hepatic diseases in patients with shoulder pain: a scoping review. Musculoskeletal Care. (2022) 20(4):721–30. doi: 10.1002/msc.1628
42. Rouleau DM, Hebert-Davies J, Robinson CM. Acute traumatic posterior shoulder dislocation. J Am Acad Orthop Surg. (2014) 22(3):145–52. doi: 10.5435/JAAOS-22-03-145
43. Kammel KR, El Bitar Y, Leber EH. Posterior Shoulder Dislocations. Treasure Island, FL: StatPearls (2025).
44. Xu W, Huang LX, Guo JJ, Jiang DH, Zhang Y, Yang HL. Neglected posterior dislocation of the shoulder: a systematic literature review. J Orthop Translat. (2015) 3(2):89–94. doi: 10.1016/j.jot.2015.02.004
45. Guido F, Venturin D, De Santis A, Giovannico G, Brindisino F. Clinical features in rotator cuff calcific tendinopathy: a scoping review. Shoulder Elbow. (2025) 17(2):121–9. doi: 10.1177/17585732241244515
46. Le Goff B, Berthelot JM, Guillot P, Glémarec J, Maugars Y. Assessment of calcific tendonitis of rotator cuff by ultrasonography: comparison between symptomatic and asymptomatic shoulders. Joint Bone Spine. (2010) 77(3):258–63. doi: 10.1016/j.jbspin.2010.01.012
47. Kim MS, Kim IW, Lee S, Shin SJ. Diagnosis and treatment of calcific tendinitis of the shoulder. Clin Shoulder Elbow. (2020) 23(4):210–6. doi: 10.5397/cise.2020.00318
48. Wu YC, Tsai WC, Tu YK, Yu TY. Comparative effectiveness of nonoperative treatments for chronic calcific tendinitis of the shoulder: a systematic review and network meta-analysis of randomized controlled trials. Arch Phys Med Rehabil. (2017) 98(8):1678–92.e6. doi: 10.1016/j.apmr.2017.02.030
49. Serafini G, Sconfienza LM, Lacelli F, Silvestri E, Aliprandi A, Sardanelli F. Rotator cuff calcific tendonitis: short-term and 10-year outcomes after two-needle us-guided percutaneous treatment–nonrandomized controlled trial. Radiology. (2009) 252(1):157–64. doi: 10.1148/radiol.2521081816
50. Cho NS, Lee BG, Rhee YG. Radiologic course of the calcific deposits in calcific tendinitis of the shoulder: does the initial radiologic aspect affect the final results? J Shoulder Elbow Surg. (2010) 19(2):267–72. doi: 10.1016/j.jse.2009.07.008
51. Simpson M, Pizzari T, Cook T, Wildman S, Lewis J. Effectiveness of non-surgical interventions for rotator cuff calcific tendinopathy: a systematic review. J Rehabil Med. (2020) 52(10):1–15. doi: 10.2340/16501977-2725
52. Brindisino F, Marruganti S, Lorusso D, Cavaggion C, Ristori D. The effectiveness of extracorporeal shock wave therapy for rotator cuff calcific tendinopathy. A systematic review with meta-analysis. Physiother Res Int. (2024) 29(3):e2106. doi: 10.1002/pri.2106
53. Sconza C, Palloni V, Lorusso D, Guido F, Farì G, Tognolo L, et al. Ultrasound-guided percutaneous lavage for the treatment of rotator cuff calcific tendinopathy: a systematic review with meta-analysis of randomized controlled trials. Eur J Phys Rehabil Med. (2024) 60(6):995–1008. doi: 10.23736/S1973-9087.24.08544-7
54. Ricci V, Mezian K, Chang KV, Özçakar L. Clinical/sonographic assessment and management of calcific tendinopathy of the shoulder: a narrative review. Diagnostics (Basel, Switzerland). (2022) 12(12):3097. doi: 10.3390/diagnostics12123097
55. Hsu J, Keener JD. Natural history of rotator cuff disease and implications on management. Oper Tech Orthop. (2015) 25(1):2–9. doi: 10.1053/j.oto.2014.11.006
56. Teunis T, Lubberts B, Reilly BT, Ring D. A systematic review and pooled analysis of the prevalence of rotator cuff disease with increasing age. J Shoulder Elbow Surg. (2014) 23(12):1913–21. doi: 10.1016/j.jse.2014.08.001
57. Tashjian RZ, Saltzman EG, Granger EK, Hung M. Incidence of familial tendon dysfunction in patients with full-thickness rotator cuff tears. Open Access J Sports Med. (2014) 5:137–41. doi: 10.2147/OAJSM.S63656
58. Gwilym SE, Watkins B, Cooper CD, Harvie P, Auplish S, Pollard TC, et al. Genetic influences in the progression of tears of the rotator cuff. J Bone Joint Surg Br Vol. (2009) 91(7):915–7. doi: 10.1302/0301-620X.91B7.22353
60. Xu T, Xia Q, Zhang L, Yang X, Fu W. Type 2 diabetes and fasting glycemic traits are causal factors of frozen shoulder: a 2-sample Mendelian randomization analysis. J Shoulder Elbow Surg. (2024) 33(2):399–408. doi: 10.1016/j.jse.2023.08.006
61. Green HD, Jones A, Evans JP, Wood AR, Beaumont RN, Tyrrell J, et al. A genome-wide association study identifies 5 loci associated with frozen shoulder and implicates diabetes as a causal risk factor. PLoS Genet. (2021) 17(6):e1009577. doi: 10.1371/journal.pgen.1009577
62. Kim JH, Baek JY, Han KD, Kim BS, Kwon HS. Higher body mass index increases the risk of shoulder adhesive capsulitis in young adults: a nationwide cohort study. J Shoulder Elbow Surg. (2025) 34(1):26–32. doi: 10.1016/j.jse.2024.03.063
63. Konarski W, Poboży T, Kotela A, Śliwczyński A, Kotela I, Hordowicz M, et al. Does diabetes mellitus increase the risk of avascular osteonecrosis? A systematic review and meta-analysis. Int J Environ Res Public Health. (2022) 19(22):15219. doi: 10.3390/ijerph192215219
64. Nevskaya T, Gamble MP, Pope JE. A meta-analysis of avascular necrosis in systemic lupus erythematosus: prevalence and risk factors. Clin Exp Rheumatol. (2017) 35(4):700–10.28240590
65. Tsai HL, Chang JW, Lu JH, Liu CS. Epidemiology and risk factors associated with avascular necrosis in patients with autoimmune diseases: a nationwide study. Korean J Intern Med. (2022) 37(4):864–76. doi: 10.3904/kjim.2020.098
66. Patton JT, Sommerville SM, Grimer RJ. Primary malignant tumours of bone following previous malignancy. Sarcoma. (2008) 2008:418697. doi: 10.1155/2008/418697
67. Roberts S, Dearne R, Keen S, Littlewood C, Taylor S, Deacon P. Routine x-rays for suspected frozen shoulder offer little over diagnosis based on history and clinical examination alone. Musculoskeletal Care. (2019) 17(2):288–92. doi: 10.1002/msc.1396
68. Salamh P, Stoner B, Ruley N, Zhu H, Bateman M, Chester R, et al. An international consensus on the etiology, risk factors, diagnosis and management for individuals with frozen shoulder: a delphi study. J Man Manip Ther. (2025) 33:309–20. doi: 10.1080/10669817.2025.2470461
69. Nordqvist JM, Öberg BE, Adolfsson LE, Holmgren TM, Johansson KM. Heterogeneity among patients with subacromial pain—variabilities within clinical presentation and its impact on daily life. Physiotherapy. (2021) 112:113–20. doi: 10.1016/j.physio.2020.10.001
70. Rechardt M, Shiri R, Karppinen J, Jula A, Heliövaara M, Viikari-Juntura E. Lifestyle and metabolic factors in relation to shoulder pain and rotator cuff tendinitis: a population-based study. BMC Musculoskelet Disord. (2010) 11:165. doi: 10.1186/1471-2474-11-165
71. Zhang Z, Ferreira GE, Downes JS, Cockburn JV, Burke WJ, Malliaras P, et al. The effectiveness of education for people with shoulder pain: a systematic review. Musculoskelet Sci Pract. (2025) 75:103246. doi: 10.1016/j.msksp.2024.103246
72. Dubé MO, Desmeules F, Lewis JS, Roy JS. Does the addition of motor control or strengthening exercises to education result in better outcomes for rotator cuff-related shoulder pain? A multiarm randomised controlled trial. Br J Sports Med. (2023) 57(8):457–63. doi: 10.1136/bjsports-2021-105027
73. Littlewood C, Moffatt M, Maher N, Irving G. Current and future advances in practice: tendinopathies of the shoulder. Rheumatol Adv Pract. (2023) 7(3):rkad086. doi: 10.1093/rap/rkad086
74. Lewis J, Mintken PE, McDevitt AW. Treating musculoskeletal conditions with a bit of exercise and manual therapy: are you kidding me? it’s time for us to evolve again. J Man Manip Ther. (2025) 33(3):167–72. doi: 10.1080/10669817.2025.2494895
75. Powell JK, Lewis J, Schram B, Hing W. Is exercise therapy the right treatment for rotator cuff-related shoulder pain? Uncertainties, theory, and practice. Musculoskeletal Care. (2024) 22(2):e1879. doi: 10.1002/msc.1879
76. Babatunde OO, Ensor J, Littlewood C, Chesterton L, Jordan JL, Corp N, et al. Comparative effectiveness of treatment options for subacromial shoulder conditions: a systematic review and network meta-analysis. Ther Adv Musculoskelet Dis. (2021) 13:1759720 ( 211037530. doi: 10.1177/1759720X211037530
Keywords: diagnostic imaging, ultrasonography, magnetic resonance imaging, clinical relevance, evidence-based practice, practice patterns, physicians'
Citation: Brindisino F, Salamh P, Cook C, Lewis J, Palese A, Guerra G, Bonavita J and Rossettini G (2025) Shoulder pain: to image or not to image?. Front. Rehabil. Sci. 6:1624056. doi: 10.3389/fresc.2025.1624056
Received: 16 June 2025; Accepted: 13 August 2025;
Published: 29 August 2025.
Edited by:
Areerat Suputtitada, Chulalongkorn University, ThailandReviewed by:
Vincenzo Ricci, Luigi Sacco Hospital, ItalyPiyapat Dajpratham, Mahidol University, Thailand
Copyright: © 2025 Brindisino, Salamh, Cook, Lewis, Palese, Guerra, Bonavita and Rossettini. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Fabrizio Brindisino, ZmFicml6aW8uYnJpbmRpc2lub0B1bmltb2wuaXQ=