Shoulder pain? Most patients may not need a scan

Clinical takeaway: For nontraumatic shoulder pain without red flags, start with history and physical examination, reassure patients about the generally favorable prognosis, encourage appropriate activity, and reserve imaging or specialist referral for concerning or persistent presentations.

Shoulder pain affects nearly 1 in 6 adults annually and is the third most common musculoskeletal complaint seen in primary care. This review challenges longstanding reliance on early imaging and procedures that may increase costs, overdiagnosis, and patient anxiety without improving outcomes.

A new JAMA Internal Medicine review challenges the common impulse to scan, inject, or operate on patients with shoulder pain. Most cases seen in primary care involve benign periarticular soft-tissue problems, with subacromial pain the most frequent presentation. After serious or referred causes are excluded, the authors recommend education, symptom relief, activity modification as needed, and watchful waiting as first-line care.

Routine early X-rays, ultrasound, or MRI are not recommended without significant trauma or red flags such as fever, unexplained weight loss, or a history of cancer. Imaging abnormalities often correlate poorly with symptoms and rarely change initial management. The authors also favor the broader label “subacromial pain” over structural diagnoses such as bursitis, impingement, or rotator cuff tear that may imply tissue damage requiring repair.

Long-term observational data cited by the researchers suggest nearly 80% of 526 adults with new shoulder concerns achieved satisfactory improvement with approaches such as watchful waiting or anti-inflammatory medication. Evidence also indicates ultrasound guidance adds little benefit to corticosteroid injections, while high-certainty evidence shows subacromial decompression surgery does not improve subacromial pain.

“Early scans don’t improve long-term recovery,” lead author Romi Haas, PhD, said, warning that common age-related findings may instead trigger worry, overdiagnosis, and unnecessary treatment.

Source: Haas R, et al. (2026 Aug 17) JAMA Intern Med. Management of Shoulder Pain in Primary Care: A Review