A prospective study of shoulder pain in primary care: prevalence of imaged pathology and response to guided diagnostic blocks

BMC Musculoskelet Disord. 2011 May 28:12:119. doi: 10.1186/1471-2474-12-119.


Background: The prevalence of imaged pathology in primary care has received little attention and the relevance of identified pathology to symptoms remains unclear. This paper reports the prevalence of imaged pathology and the association between pathology and response to diagnostic blocks into the subacromial bursa (SAB), acromioclavicular joint (ACJ) and glenohumeral joint (GHJ).

Methods: Consecutive patients with shoulder pain recruited from primary care underwent standardised x-ray, diagnostic ultrasound scan and diagnostic injections of local anaesthetic into the SAB and ACJ. Subjects who reported less than 80% reduction in pain following either of these injections were referred for a magnetic resonance arthrogram (MRA) and GHJ diagnostic block. Differences in proportions of positive and negative imaging findings in the anaesthetic response groups were assessed using Fishers test and odds ratios were calculated a for positive anaesthetic response (PAR) to diagnostic blocks.

Results: In the 208 subjects recruited, the rotator cuff and SAB displayed the highest prevalence of pathology on both ultrasound (50% and 31% respectively) and MRA (65% and 76% respectively). The prevalence of PAR following SAB injection was 34% and ACJ injection 14%. Of the 59% reporting a negative anaesthetic response (NAR) for both of these injections, 16% demonstrated a PAR to GHJ injection. A full thickness tear of supraspinatus on ultrasound was associated with PAR to SAB injection (OR 5.02; p < 0.05). Ultrasound evidence of a biceps tendon sheath effusion (OR 8.0; p < 0.01) and an intact rotator cuff (OR 1.3; p < 0.05) were associated with PAR to GHJ injection. No imaging findings were strongly associated with PAR to ACJ injection (p ≤ 0.05).

Conclusions: Rotator cuff and SAB pathology were the most common findings on ultrasound and MRA. Evidence of a full thickness supraspinatus tear was associated with symptoms arising from the subacromial region, and a biceps tendon sheath effusion and an intact rotator cuff were associated with an intra-articular GHJ pain source. When combined with clinical information, these results may help guide diagnostic decision making in primary care.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Acromioclavicular Joint / diagnostic imaging
  • Acromioclavicular Joint / pathology
  • Adolescent
  • Adult
  • Aged
  • Aged, 80 and over
  • Bursa, Synovial / diagnostic imaging
  • Bursa, Synovial / pathology
  • Female
  • Humans
  • Joint Diseases / complications
  • Joint Diseases / diagnosis*
  • Joint Diseases / diagnostic imaging
  • Joint Diseases / pathology
  • Joint Diseases / therapy
  • Magnetic Resonance Imaging*
  • Male
  • Middle Aged
  • Nerve Block*
  • New Zealand
  • Odds Ratio
  • Pain Measurement
  • Predictive Value of Tests
  • Primary Health Care*
  • Prospective Studies
  • Rotator Cuff / diagnostic imaging
  • Rotator Cuff / pathology
  • Shoulder Fractures / complications
  • Shoulder Fractures / diagnosis*
  • Shoulder Fractures / diagnostic imaging
  • Shoulder Fractures / pathology
  • Shoulder Fractures / therapy
  • Shoulder Joint / diagnostic imaging
  • Shoulder Joint / pathology
  • Shoulder Pain / diagnosis*
  • Shoulder Pain / diagnostic imaging
  • Shoulder Pain / etiology
  • Shoulder Pain / pathology
  • Shoulder Pain / therapy
  • Tendon Injuries / complications
  • Tendon Injuries / diagnosis*
  • Tendon Injuries / diagnostic imaging
  • Tendon Injuries / pathology
  • Tendon Injuries / therapy
  • Ultrasonography
  • Young Adult