Which imaging modalities are recommended for the assessment of shoulder pain in primary care, and when should they be utilized?

In primary care, routine imaging is not recommended initially for the assessment of shoulder pain unless red flags or atypical features are present, such as trauma with loss of function, suspected malignancy, infection, or neurological deficits. Clinical diagnosis and management should be the first approach NICE CKS.

Plain radiographs (X-rays) may be considered if there is suspicion of fracture, dislocation, or osteoarthritis, particularly in people aged 45 or over with activity-related joint pain and typical osteoarthritis symptoms, but imaging is not routinely required to diagnose osteoarthritis unless atypical features or alternative diagnoses are suspected NICE CKS,NICE NG226.

Ultrasound is recommended as a first-line imaging modality for suspected rotator cuff disorders or subacromial pathology in primary care due to its accessibility, cost-effectiveness, and ability to detect tendon tears and bursitis. It can guide management decisions and referrals Expert Panel on Musculoskeletal Imaging et al. 2023Toh 2024.

MRI is reserved for cases where ultrasound findings are inconclusive, or when there is suspicion of complex pathology such as acute rotator cuff tears, neurological involvement, or when surgical intervention is being considered. MRI provides detailed soft tissue contrast and is the preferred modality for assessing the extent of rotator cuff tears and other intrinsic shoulder disorders NICE CKS Expert Panel on Musculoskeletal Imaging et al. 2023Toh 2024.

Urgent imaging and referral (including MRI) should be arranged if red flags are present, such as severe trauma with loss of active movement, suspected septic arthritis, malignancy, or neurological deficits NICE CKS.

In summary, primary care assessment of shoulder pain relies primarily on clinical evaluation, with imaging reserved for specific indications: X-rays for suspected fracture or osteoarthritis with atypical features, ultrasound as the first-line for rotator cuff pathology, and MRI for complex or unclear cases or pre-surgical planning NICE CKS,NICE NG226 Expert Panel on Musculoskeletal Imaging et al. 2023Toh 2024.