Shoulder pain can be frustrating. It can affect sleep, make it difficult to reach overhead, and interfere with work, sport and everyday activities.
When this happens, many people assume that an MRI or ultrasound is the next step. However, current evidence suggests that for most people with shoulder pain, a scan is not needed during the early stages of management.
In many cases, a thorough assessment by an experienced physiotherapist provides more useful information than an immediate MRI or ultrasound. This is because scans do not tell the whole story. Imaging often identifies age-related changes such as tendon degeneration, bursitis or partial tears that are also commonly seen in people who have no shoulder pain. These are known as incidental findings. To determine whether a scan finding is relevant, it must be considered alongside a person’s symptoms, physical examination and functional limitations. For most people presenting with non-traumatic shoulder pain, current clinical guidelines recommend that diagnosis and early management should be guided primarily by a thorough clinical assessment (Desmeules et al., 2025). Imaging should be used selectively and in conjunction with the clinical picture rather than as a routine first step.
Importantly, obtaining a scan early does not necessarily improve recovery or change the initial management of shoulder pain. In many cases, treatment decisions can be made based on a thorough history and physical examination, with imaging reserved for situations where symptoms are not improving after an appropriate course of treatment, a significant traumatic injury is suspected, or there is concern about a full-thickness rotator cuff tear.
What can a physiotherapist learn without a scan?
A great deal.
A comprehensive assessment provides valuable information about what is contributing to your symptoms and how best to manage them. This typically includes:
- Understanding how the symptoms began
- Assessing pain patterns and aggravating activities
- Measuring shoulder movement
- Assessing strength and function
- Screening for other possible causes of shoulder pain
- Identifying factors that may affect recovery, such as work demands, sporting activities and previous injuries
When is a scan helpful?
This does not mean that scans are never useful. There are situations where imaging can provide valuable information and help guide management. Current recommendations suggest imaging may be appropriate when:
- Symptoms are not improving after approximately 12 weeks of appropriate non-surgical treatment
- A significant traumatic injury has occurred
- A full-thickness rotator cuff tear is suspected
- There are signs of a more serious underlying condition
- Surgical consultation is being considered
In these situations, imaging can assist with diagnosis and decision-making.
Ultrasound or MRI?
Many people assume that MRI is automatically the best option, but that is not always the case.
For rotator cuff-related shoulder pain, current clinical guidelines recommend prioritising diagnostic ultrasound when imaging is required. Ultrasound offers similar diagnostic accuracy to MRI for many rotator cuff disorders while typically being less expensive and more accessible (Desmeules et al., 2025).
MRI may still be appropriate in more complex situations, particularly when there is suspicion of additional shoulder pathology or when surgical planning is required.
So, do you need a scan?
For most people, the best starting point is a thorough assessment rather than an MRI referral.
A physiotherapist for shoulder pain can usually determine whether your symptoms are likely to improve with rehabilitation, whether imaging may be helpful later, or whether referral for further investigation is appropriate.
If your shoulder pain is not improving after several weeks of appropriate treatment, or there are signs suggesting a more significant injury, a scan may become part of the picture. However, scans are only one piece of the puzzle. For many people, understanding the factors contributing to their shoulder pain and following an appropriate management plan is far more important than the scan itself.
References
Desmeules, F., Roy, J.-S., Lafrance, S., Charron, M., Dubé, M.-O., Dupuis, F., Beneciuk, J. M., Grimes, J., Kim, H. M., Lamontagne, M., McCreesh, K., Shanley, E., Vukobrat, T., & Michener, L. A. (2025). Rotator cuff tendinopathy diagnosis, nonsurgical medical care, and rehabilitation: A clinical practice guideline. Journal of Orthopaedic & Sports Physical Therapy, 55(4), 235–274.
Ibounig, T., Järvinen, T. L. N., Raatikainen, S., et al. (2026). Prevalence of rotator cuff abnormalities in symptomatic and asymptomatic adults: Findings from the Finnish Imaging of Shoulder (FIMAGE) study. JAMA Internal Medicine, 186(4).
Lin, I., Wiles, L., Waller, R., Goucke, R., Nagree, Y., Gibberd, M., Straker, L., Maher, C. G., O’Sullivan, P. P., & Hitchins, M. J. (2020). What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: Systematic review. British Journal of Sports Medicine, 54(2), 79–86.
Yamaguchi, K., Ditsios, K., Middleton, W. D., Hildebolt, C. F., Galatz, L. M., & Teefey, S. A. (2006). The demographic and morphological features of rotator cuff disease: A comparison of asymptomatic and symptomatic shoulders. The Journal of Bone and Joint Surgery, 88(8), 1699–1704.
Jack Melbourne is an experienced, APA Titled Musculoskeletal Physiotherapist with a clinical focus on shoulder conditions. He holds a Bachelor of Exercise Science, a Doctor of Physiotherapy, and a Master of Musculoskeletal Physiotherapy. Jack works at Lifecare Langwarrin Sports Medicine Centre where he uses an evidence-based approach to assess and manage shoulder pain, helping patients return to their previous level of function and get back to the things they enjoy.