Most shoulder problems are a result of rotator cuff damage, joint instability or dislocation, glenohumeral joint arthritis, or biceps problems. Other issues include impingement, acromioclavicular problems, and adhesive capsulitis (frozen shoulder). Most of these conditions are amenable to surgery if non-operative measures including physiotherapy fail.

A screening xray is usually appropriate for most shoulder problems, especially in older patients where osteoarthritis is suspected. If a non-bony or non-arthritic problem is suspected, and initial conservative treatment is unsuccessful, an eventual MRI can be ordered. A pertinent history of the shoulder problem should be included on the requisition, as this can facilitate a more helpful radiologic interpretation.

Most non-traumatic rotator cuff problems, including tendinosis and attritional cuff tears in patients over 60 years of age, can be treated with an initial 3 month period of physiotherapy. This should be initiated prior to referral for surgical consideration. The remaining intact rotator cuff can often compensate for the torn portion, obviating the need for surgery. If a cuff tear results from a specific injury, earlier referral is indicated. A cortisone injection can be tried in non-traumatic rotator cuff problems if significant pain persists. Physiotherapy is not contraindicated with acute or chronic cuff tears.

Many rotator cuff tears can be effectively treated with surgery, though chronic, retracted tears with significant muscle atrophy or fatty infiltration on MRI may not. Even in these patients physiotherapy can often be of some benefit. Reverse shoulder arthroplasty is a newer surgical option for patients with arthritis associated with large irreparable cuff tears, though this is not a procedure we perform in Brandon, necessitating a referral to Winnipeg. It is important to note that many rotator cuff tears in those over 65 are in fact asymptomatic, and may not even come to attention.

For first time shoulder dislocations in those under 30 years of age, early referral is usually suggested, as there is merit in surgical correction before tissue is permanently damaged from recurrent dislocations. In primary dislocations over the age of 40, recurrence is not usually a problem but an associated rotator cuff tear often occurs. If the recently dislocated shoulder does not improve satisfactorily with physiotherapy after 1 to 2 months, an MRI can identify these cuff tears. Dislocations in patients under 30 often become recurrent and usually can be treated with arthroscopic surgical stabilization.

Glenohumeral or shoulder osteoarthritis is often better tolerated than knee or hip arthritis even when apparently severe on xray, and can usually be managed for some time with conservative treatment. When pain, especially rest pain, stiffness, and dysfunction become significant, referral for consideration of replacement is appropriate.

Osteoarthritis of the AC joint is commonly noted on X-ray or MRI, and often is an incidental age-related finding only, not requiring any particular treatment. If it does in fact become a problem, excision of the lateral clavicle can be helpful. AC instability occasionally requires surgical instability, though most AC separations can be treated non-operatively.

Many shoulder problems can result in disuse rotator cuff weakness, leading to secondary subacromial impingement and pain. Impingement tests on physical examination are typically positive, and imaging may not be diagnostic aside from possibly showing mild subacromial narrowing. Often rehabilitating and strengthening the cuff muscles with the help of physiotherapy can reduce the impingement pain, avoiding the need for surgery. A subacromial cortisone injection can be beneficial. Shoulder impingement from cuff disease and subacromial osteophytes can sometimes be a primary problem, and imaging can occasionally demonstrate an impinging anterior osteophyte. If conservative treatment fails, an arthroscopic subacromial decompression in these cases may be considered.

Adhesive capsulitis, or frozen shoulder is a poorly understood condition, more common in diabetics, arising from recent surgery, minor injury, or even spontaneously. It is usually self limited, though it can sometimes take a year or more to resolve and can occasionally eventually be bilateral. Full activities and exercises within the restricted range are encouraged with the help of physiotherapy. Moist heat and sometimes an intra-articular cortisone injection can be helpful. Usually functional range of motion will be restored without surgical intervention, and patience must be encouraged to wait for eventual biological healing and recovery.

For most shoulder patients it is helpful if physiotherapy is initiated before or at least at the time of referral. An MRI need not necessarily be ordered or completed prior to referral. Sleep disturbance is a common accompanying symptom, and sometimes needs to be addressed independently. It is also important to consider the possibility that a primary cervical spine condition with potential concomitant neurological involvement is at least part of the problem and needs to be diagnosed.