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     There are four necessary components to develop a treatment plan for managing shoulder pain. I believe each component is equally important. Too many times we jump to the conclusion without going through the appropriate steps to get there. That's how errors are made.

     This website is designed to take you through that process. It is not intended to provide surgical treatment options for different diagnoses based on an MRI finding. That information can be found elsewhere. It is also not intended to make a diagnosis nor recommend a particular treatment option. As I hope you will see, the best treatment can only be determined by a careful review of all four of these components. This is the art of treating shoulder pain!

Shoulder history
The History

The history is a very important component of developing an appropriate treatment plan. Unfortunately, it is often neglected or abbreviated duing a busy office schedule. Failure of a physican to ask the appropriate questions or a patient to provide an accurate history can lead down a path towards an inadequate treatment. Be prepared to tell your doctor as much information as you can about your shoulder pain. Some common questions are:

1. Where does it hurt?

2. How long has it been painful?

3. What factors aggrevate the pain?

4. Does the shoulder make noises or feel unstable?

5. What activities do you like to do?

6. Is this your dominate hand?

7. What other medical conditions do you have?

8. What other treatments have you tried? Were they effective?

9. Did you injure the shoulder? If so, how?

Shoulder examination
The Physical Examination

The physical examination is the second step towards developing a treatment plan. After the history, I usually have narrowed down my possible diagnoses to just a handful. The examination helps narrow this even further. During the exam it is important to:

1. Inspect the appearance of the shoulder.

2. Palpate (press on) different locations to determine whether there is tenderness or muscle spasm.

3. Test the range of motion in all three planes.

4. Test the shoulder strength in multiple directions.

5. Assess the neck and neurologic function further down the arm.

6. Perform more specific tests to determine instability, a possible tear, pain from the neck, inflammation of the tendons, etc. There are multple different tests for specific shoulder pathology. Usually only a few are needed based on the possible diagnoses obtained during the history.

shoulder mri
Radiologic Testing

The third step in the process is to obtain appropriate diagnostic test. After the examination, I frequently know the diagnosis are only have a few other possibilities.  Diagnostic testing is used to confirm the diagnosis or exclude the other possibilities. 

1. The most common test is the X-Ray. This is good for bony structures and evaluating arthritis. It can also rule out less common problems such as a bone tumor.

2. Ultrasound has recently gained popularity for it's ability to evaluate the soft tissue structures of the shoulder such as the rotator cuff and look for areas of fluid collections. It is cheaper than an MRI and more easily accessable. However, it is very operator dependent to obtain good images.

3. The best test for looking at the soft tissues is an MRI. It can evaluate deeper structures such as the carilage and tendons. However, the accuracy is also very dependent upon the quality of the MRI machine. Many diagnoses are missed because of a poor quality MRI image. 

shoulder diagnosis
Make a Diagnosis

Now that the testing has been completed, it is time to make a diagnosis. The physician should not recommend a treatment plan unless there is a good working idea of what is causing the problem. The history, exam and diagnostic tests are combined with the surgeon's expertise to determine the correct diagnosis. At times, there may be more than one diagnosis. In these cases, it is important to determine which diagnosis is the primary source of the pain. Localized injections of steroid or an anesthetic are helpful in this regard. If the pain significantly improves with an injection in one part of the shoulder, that region is the source of the pain. Now we can move on to an effective treatment plan!

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