Shoulder pain: why physios start with exercise before an MRI

A shoulder that starts aching for no clear reason, perhaps after a weekend of painting or a new gym program, is one of the most common problems a physio sees. The pain sits on the outside of the upper arm. It flares when you reach overhead and wakes you when you roll onto that side.

Plenty of people arrive at the first appointment asking for an MRI. Most don’t need one yet. When there was no fall or obvious injury, Australian physios start with a graded exercise program and keep scans for cases where the result would change the plan.

Scans pick up a lot of wear that has nothing to do with pain.

In 1995, Sher and colleagues scanned 96 adults whose shoulders felt fine. MRI showed a rotator cuff tear in 34% of them. In those over 60, the figure was 54% ^[1].

That changes how to read a report. “Partial tear” or “tendinopathy” on paper does not prove that’s what hurts, and the change may have been there for years.

Over-reading a scan has a cost too. Some people start guarding the arm after seeing the word “tear”, and a stiff, unused shoulder gets worse. A report can also push someone towards an operation they didn’t need.

For many common shoulder problems, exercise holds up well. It is slower, and it doesn’t work for everyone.

Subacromial decompression was one of the most common shoulder operations for years. The surgeon shaves bone to give the tendons more room.

Two large trials, one British and one Finnish, tested it against a placebo-style procedure in which the surgeon only looked inside the joint. Neither found a clinically meaningful benefit from the real operation ^[2][3]. The Finnish trial also had a group who did exercise alone. Their results came out close to both surgical groups ^[3].

A US multicentre study put patients with full-thickness rotator cuff tears that didn’t come from an injury through physical therapy first. Two years on, about three in four had still not chosen surgery ^[4].

Most of those who did choose an operation made the call within the first 12 weeks. Of all the figures here, that one is the most practical. It gives you a fair point to stop and reassess.

Load goes up in steps so the tendon can adapt without flaring. No two plans are identical, though most follow a rough shape.

Cut back on whatever sets it off. Long stretches of overhead work are the usual culprit, along with sleeping on that side. Keep using the arm for everyday tasks.

Isometric holds help early. You press the arm into a wall without letting it move, and hold.

One rule runs through the whole program: some discomfort during an exercise is fine if it has settled by the next morning.

Resistance bands come out now. Turning the arm outward against the band gets most of the attention, with shoulder blade work added alongside. When a full set feels easy, the band gets heavier.

Reaching and lifting return gradually. Then your physio adds whatever your job or sport asks of the shoulder. For a tradie that might mean holding a drill above head height for minutes at a time. For a swimmer it’s the long reach at the front of each freestyle stroke.

Clear change tends to show between 6 and 12 weeks. If you’ve done the work and have little to show for it by then, imaging starts to make sense, often ultrasound or MRI.

Dry needling and manual therapy can take the edge off pain along the way. The evidence for them is mixed, and they work best as an add-on to the exercise program.

A younger person who falls onto an outstretched arm and suddenly can’t lift it is a different case. That points to an acute traumatic rotator cuff tear. Early repair does better here, so imaging and an orthopaedic opinion come first.

An X-ray also belongs early when the shoulder is badly stiff in every direction. It shows arthritis and calcium deposits in a tendon.

Get a medical assessment promptly, on the same day if you can, for any of the following:

• A dislocation or visible deformity after an injury
• Fever with a hot, swollen joint, which can signal infection
• New numbness or weakness down the arm
• Unexplained weight loss, or constant night pain that no position eases

Shoulder pain that comes with chest tightness or shortness of breath can be a heart problem. Call 000 straight away.

You don’t need a GP referral to see a physio privately in Australia.

Medicare is another matter. A rebate needs a GP Chronic Condition Management Plan (GPCCMP, the plan that replaced the CDM or EPC plan). Physio sessions on the plan are claimed under MBS item 10960. You get five rebated sessions each calendar year, and those five are shared across every allied health service, so a podiatry visit uses one as well.

At Eastside Physio + Co in Surrey Hills, shoulder pain treatment in Melbourne starts with graded exercise. The clinic orders an X-ray or MRI only when the result would change how the shoulder is managed. Significant trauma, or a suspected full-thickness tear in a younger patient, gets referred on to a GP or orthopaedic surgeon.

Five rebated sessions won’t cover a 12-week program on their own. At the first visit, ask how many appointments the plan needs and how much of the work you’ll do at home.

Bring any scans you already have. Some of what’s on the report will matter for your shoulder. Some of it is normal for your age, and a physio can tell you which is which.

1. Sher JS, Uribe JW, Posada A, et al. Abnormal findings on magnetic resonance images of asymptomatic shoulders. J Bone Joint Surg Am. 1995;77(1):10–15.

2. Beard DJ, Rees JL, Cook JA, et al. Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW). Lancet. 2018;391(10118):329–338.

3. Paavola M, Malmivaara A, Taimela S, et al. Subacromial decompression versus diagnostic arthroscopy for shoulder impingement. BMJ. 2018;362:k2860.

4. Kuhn JE, Dunn WR, Sanders R, et al. Effectiveness of physical therapy in treating atraumatic full-thickness rotator cuff tears. J Shoulder Elbow Surg. 2013;22(10):1371–1379.