Shoulder pain and X-rays – do shoulder x-rays mean anything?

The most common myth about shoulder X-rays for shoulder pain

The vast majority of people believe that shoulder X-rays are a good way to determine what's causing shoulder pain.

Stress, among other things, can make your shoulder muscles quite cranky.

Many doctors also say that an X-ray is a good way to investigate shoulder pain. They might find things like medial acromial and lateral clavicular sclerosis, subchondral acromial cysts, inferior acromial and clavicular osteophytes, and degeneration of the acromioclavicular joint...

Those all sound terrible, don't they?

If you saw any of those things in a shoulder X-ray, you'd think those were the obvious cause of your pain. You'd also probably think that treating those problems would cure your pain. 

But that's not the reality!

In fact, that list of shoulder pathologies above comes from a study done way back in 2000. In the study, they looked at the shoulder X-rays for 84 people with no shoulder pain and no shoulder symptoms.

They found all of those nasty diagnoses, but none were linked to pain. None of the people in the study had shoulder pain. Again: nobody had shoulder pain. 

The "degeneration" seen in the X-rays seemed to be related to age. It was unrelated to actually having shoulder problems. That means the stuff in the shoulder X-rays wasn't causing shoulder pain.  If these things don't cause pain you might wonder, "why call them degeneration?"

The answer is because that's simply what these things have always been called. It's just a matter of convention. A better term might be "deviation" - because the things we currently call degeneration don't seem to be related to shoulder pain.

But maybe this is just an isolated case of unreliable X-rays? Perhaps we're making too much of this one study? 

A shoulder X-ray is like a spine X-ray

Yup. Still don't know why you have back pain.

For many decades, doctors used to  recommend X-rays for back pain. If they found signs of spinal degeneration, they would say that the degeneration was causing back pain. It could have been a bulging disc, some signs of arthritis, or the narrowing or shifting of some vertebra.

 For decades,  doctors considered surgery the best way to "correct" those issues and treat back pain. Then, one day, medical research showed that the "degeneration" wasn't related to pain at all.

Except in rare severe cases, researchers could find signs of spine degeneration in large numbers of asymptomatic people (with no pain!) over 30 years of age. Even some spine surgeons started to point out that the spinal surgeries weren't working as well as they were supposed to.

The modern research on spinal degeneration is pretty clear: the X-ray results don't mean much!

Unfortunately, some spinal surgeons truly believe they are helping people by performing unproven surgeries (and they may also have financial incentives/pressures that make it harder for them to accept research on spinal surgery).

X-rays on hips show the same phenomenon. Even people with severe signs of arthritis can walk around with no pain in their hips. But on the other hand, people with intense pain in their hips may have no signs of arthritis on an X-ray.

X-ray evidence of degeneration, again, means nothing. The point is that X-rays simply cannot identify the source of a person's shoulder pain with any reliability. It doesn't work in the spine, the hips, or the shoulders.

Overall, there is little evidence that what shows up in an X-ray tells you anything about what is causing your shoulder pain! 

What are shoulder X-rays missing?

Shoulder X-rays don't tell you anything about muscles.

People often think that since a shoulder X-ray is zooming in on the bones, it's showing you everything you need to know about shoulder pain. As you've already seen, this isn't the case. X-rays are showing you things that aren't related to shoulder pain.

When the shoulder hurts, we need to look at the muscles.

Why look at muscles? Because muscles are responsible for controlling the pain-free, safe range of motion of every single joint in the body.

You want to lift your knee toward your chest? Muscles have to do that.

You want to lift your hand up toward the top shelf? Muscles have to do that.

You want to type on the keyboard? Muscles have to do that.

A shoulder x-ray won't tell you what muscles are doing because that's just not what a shoulder x-ray does. When muscles don't have the strength or coordination to execute a motion, undesirable things happen - like pain. 

How can muscles cause shoulder pain?

Let's start with a really obvious example so you can see how muscles can cause shoulder pain.

You're going for the longest
dumbbell bicep curl ever....

Imagine you're holding a fifteen pound (seven kilogram) weight in your hand with your elbow bent - like a bicep curl. Imagine holding it for a full minute. 

You'd probably get some burning and shaking going. But it wouldn't hurt too bad.

After five minutes, however, your forearm and upper arm muscles (which directly affect your shoulder) would start giving you some pretty painful feedback!

Another example is when muscles simply stiffen up and do not control a range of motion well because of lack of use.

Right now, you can probably open and close your fingers without much problem. Now, imagine you wrap your hand in tape so that it's stuck in a fist for the next month. When you unwrap the hand, how is it going to feel to open and close your fingers?

It's going to be stiff, painful, and achy.

You may get burning sensations, and your hand will cramp up. Heck, during that month of being wrapped up you probably would feel stiffness, pain, and aching.

The important thing to realize is that the tape around your fist wasn't the cause of your hand hurting. If you held your hand in a fist for a month, you'd have the same problem.

It's not the bones or the tape causing the problem. It's the muscles being stuck in a paralyzed position!

When your muscles are stuck and have trouble moving, they let you know with pain. Your muscles are designed to literally beg for proper motion.

An X-ray would do nothing to identify the cause of pain. You might find signs of arthritis in the fingers, but the solution wouldn't be surgery or pain pills. The solution would be gradually reintroducing movement.

Now, think about your shoulders. If your shoulder muscles are constantly limited to a small range of motion, you end up with the same kind of pain and stiffness.

Most people in the modern age have limited shoulder mobility - because they don't move their shoulders enough!

Will moving solve shoulder pain?

Moving in the RIGHT ways will help solve shoulder pain, but moving in the wrong ways won't. NOT MOVING AT ALL is definitely not a solution. Unfortunately, that's the medical advice a lot of people get.  We've seen it happen with tons of our clients.

Say our client has shoulder pain. She does a shoulder X-ray and finds something "bad" like arthritis.

The doctor says, "Okay, it's damaged. DON'T MOVE IT ANYMORE." 

Guess what?  After a month of that, she's LOST range of motion and comfort in her shoulder. 

The doctor takes a look at it again and says, "Don't move it. It's really damaged. That's why it hurts so bad." So she doesn't move it, and the shoulder just keeps right on hurting. Now she thinks the problem is that her shoulder is so bad she can't move it at all! 

Every subsequent doctor says, "Don't move it! It's damaged!" And then the cycle just continues as the pain lingers, possibly getting worse as the muscles get more and more atrophied.

Why don't doctors look at muscles?

Some people might argue that doctors do. Or that physical therapists do. But when diagnosing shoulder problems, medical professionals generally start by diving into images, like X-ray and MRI, to find "concrete" answers. Then, muscles get neglected.

One problem is that muscles aren't easily measured and analyzed in the way that doctors like to measure and analyze things. Doctors are searching for the quick concrete answer. An X-ray is a clear image. An MRI is a clear image. A blood test has some concrete numbers. We can't measure muscles in such a concrete way.

It's like your car mechanic trying to examine your car with a camera. You cannot take a picture of a car and say, "There, it works." You actually have to drive the car and test its functions to make sure that it's in good shape! 

There are technologies like EMG, but EMGs are not really an efficient way to test muscles. They also aren't that accurate.

There's manual muscle testing, but that's often rudimentary at best. Many times, textbooks on muscle testing show tests for muscle groups in one position. And only one position.

The assumption is that if a muscle works well in one position, it works in all positions. But that's not the case in dynamic, three-dimensional movement.

Believe it or not, the entire world is only beginning to scratch the surface of how muscles function. Many of the physical tests that western medicine has created to test muscles and test for physical ailments are actually wildly unreliable.

We have to put muscles into various angles and positions to know whether they function in those specific angles and positions.

There's another shocking fact that you may not be aware of, and I choked on my own spit when I read this in a book by an orthopedic surgeon. In the book, the surgeon generally advises that people do EVERYTHING they can to avoid surgery. He explains many reasons why he's come to that position. 

One of the big reasons is that medical doctors in the U.S. receive a shockingly short education in musculoskeletal anatomy. In the best case scenario, doctors get two weeks of musculoskeletal anatomy training during their entire time at school. And that's the best case. In some cases, it's only a few days. During all their years of training, your run-of-the-mill doctor will not have had a lot of exposure to working with and understanding muscles! 

Muscles just don't get a fair shake, and that drastically affects how doctors see pain.

The final word on X-rays and shoulder pain

If you've got shoulder pain and are hoping a shoulder X-ray is going to help you solve the problem, remember that X-rays have never been good at identifying the cause of chronic or recurring pain.

There's a long history of the medical world putting too much emphasis on X-rays (of course if there's a MAJOR issue that shows up - like some kind of very rare bone damage - then you might have something to deal with).  

When you have signs of run-of-the-mill degeneration, the shoulder X-ray means just about nothing! And that seems to be true if you're talking about the shoulder, the spine, and the hips! 

And the converse of the situation is true as well: you can have shoulder pain and show nothing on a shoulder X-ray. 

If the things that show up in a shoulder X-ray don't have any relationship to pain, then it's a good idea to put your attention elsewhere. That's why we encourage people to look at the muscles. Your shoulder muscles are begging for attention, and if you're like most modern human beings, you've been neglecting those muscles for years!