PRIMARY CARE SERIES

Impact of Radiographic Imaging of the Shoulder Joint on

Patient Management: An Advanced-Practice Physical
Therapist’s Approach
http://utpjournals.press/doi/pdf/10.3138/ptc.2016-41PC - Friday, May 04, 2018 4:59:58 AM - University of Winnipeg IP Address:142.132.1.147

Helen Razmjou, PT, PhD;*†‡ Monique Christakis, MD, FRCPC; § ¶

Deborah Kennedy, BSc, PT, MSc;*‡** Susan Robarts, BSc, BHScPT, MSc;*
Richard Holtby, FRCSC ††

ABSTRACT
Purpose: Recent care innovations using advanced-practice physical therapists (APPs) as alternative health care providers are promising. However,
information related to the clinical decision making of APPs is limited with respect to ordering shoulder-imaging investigations and the impact of these
investigations on patient management. The purpose of this study was twofold: (1) to explore the clinical decision making of the APP providing care in a
shoulder clinic by examining the relationship between clinical examination findings and reasons for ordering imaging investigations and (2) to examine the
impact on patient management of ordered investigations such as plain radiographs, ultrasound (US), magnetic resonance imaging (MRI), and magnetic
resonance arthrogram (MRA). Method: This was a prospective study of consecutive patients with shoulder complaints. Results: A total of 300 patients
were seen over a period of 12 months. Plain radiographs were ordered for 241 patients (80%); 39 (13%) received MRI, 27 (9%) US, and 7 (2%) MRA.
There was a relationship between clinical examination findings and ordering plain radiographs and US (ps ¼ 0.047 to <0.0001). Plain radiographs
ordered to examine the biomechanics of the glenohumeral joint affected management (w21 ¼ 8.66, p ¼ 0.003). Finding a new diagnosis was strongly
correlated with change in management for all imaging investigations (ps ¼ 0.001 to <0.0001). Conclusion: Skilled, extended-role physical therapists
rely on history and clinical examination without overusing costly imaging. The most important indicator of change in management was finding a new
diagnosis, regardless of the type of investigation ordered.
Key Words: advanced practice; diagnostic imaging; primary care; shoulder joint.

RÉSUMÉ
Objectif : innovation récente, la prestation de certains actes autrefois réservés aux chirurgiens orthopédistes par les physiothérapeutes en pratique
avancée (PPA) est prometteuse. Cependant, on en connaı̂t peu sur le lien entre la prise de décision clinique des PPA et les demandes de tests d’imagerie
de l’épaule, ainsi que sur l’influence de ces tests sur la prise en charge des patients. Cette étude avait deux objectifs : 1) étudier la prise de décision
clinique de PPA exerçant dans une clinique de l’épaule en examinant la relation entre les résultats de l’examen clinique et les motifs des demandes de
tests d’imagerie et 2) examiner l’influence des tests demandés sur la prise en charge du patient, par exemple les radiographies simples, les échographies,
les imageries par résonance magnétique (IRM) et les arthrographies par résonance magnétique (ARM). Méthodologie : cette étude prospective a été me-
née auprès de patients consécutifs se plaignant de problèmes à l’épaule. Résultats : au total, 300 patients ont été pris en charge sur une période de 12
mois. On a demandé des radiographies simples pour 241 patients (80 %), dont 39 (13 %) ont subi une IRM, 27 (9 %) une échographie et 7 (2 %) une ARM.
On a observé un lien entre les résultats de l’examen clinique et la demande de radiographies simples et d’échographies (valeurs ps de 0,047 à <0,0001).
Les radiographies simples demandées pour examiner la biomécanique de l’articulation scapulo-humérale ont eu une influence sur la prise en charge
(w21 ¼ 8,66, p ¼ 0,003). La pose d’un nouveau diagnostic a été fortement corrélée à un changement de la prise en charge pour tous les tests d’imagerie
(valeurs ps de 0,001 à <0,0001). Conclusion : les physiothérapeutes compétents ayant un champ de pratique élargi se fient à l’historique du patient et
aux examens cliniques sans abuser des tests d’imagerie coûteux. L’indicateur de changement le plus important dans la prise en charge a été la pose d’un
nouveau diagnostic, peu importe le type de test demandé.

From the: *Department of Rehabilitation; ††Department of Orthopaedic Surgery, Holland Orthopaedic & Arthritic Centre; †Sunnybrook Research Institute;
§Department of Medical Imaging, Sunnybrook Health Sciences Centre; ‡Department of Physical Therapy; ¶Department of Medical Imaging, Faculty of Medicine,
University of Toronto, Toronto; **School of Rehabilitation Science, McMaster University, Hamilton, Ont.
Correspondence to: Helen Razmjou, Holland Orthopaedic & Arthritic Centre, 43 Wellesley St. E., Toronto, ON M1Y 1H1; helen.razmjou@Sunnybrook.ca.
Contributors: All authors designed the study; or collected, analyzed, or interpreted the data; and drafted or critically revised the article and approved the final draft.
Competing Interests: This study was funded by the Practice Based Research funds of the Sunnybrook Health Sciences Centre. Helen Razmjou was partially
supported by the HMSK Clinician Investigator Funding Program and the Suzanne and William Holland Funding, Sunnybrook Health Sciences Centre, during the
study period.
Physiotherapy Canada 2017; 69(4);351–360; doi:10.3138/ptc.2016-41PC

351
 352
Recent care innovations in using advanced-practice
physical therapists (APPs) as alternative health care pro-
viders and the first assessors of patients with musculos-
keletal problems are promising. This new role maximizes
human resources by redistributing the clinical workload
of orthopaedic surgeons to physical therapists with ex-
tended roles. APPs have demonstrated expert-level clinical
decision making and the ability to facilitate specialist
care by triaging for surgical consultation and ordering
http://utpjournals.press/doi/pdf/10.3138/ptc.2016-41PC - Friday, May 04, 2018 4:59:58 AM - University of Winnipeg IP Address:142.132.1.147
diagnostic imaging investigations while maintaining high
patient satisfaction.1–6 Choosing appropriate investiga-
tions—those that provide accurate information without
adding unnecessary cost to an overloaded health care
system—is imperative for all clinicians, and because
APPs have an extended scope of practice, it is critical to
ensure that advanced imaging is used judiciously.
Plain radiographs are the initial investigation of choice
for confirming or ruling out several shoulder pathologies.7–9
However, more expensive modes of advanced imaging,
such as ultrasound (US), magnetic resonance imaging
(MRI), and magnetic resonance arthrogram (MRA), may
be needed to accurately describe and quantify any effect
on soft tissue. Despite the high level of accuracy of US
and MRI,10–13 researchers have noted that these imag-
ing investigations have several limitations. For example,
achieving an accurate US depends on the operator, who
must comply with the procedure protocol and have
comprehensive knowledge of pathologies and potential
technical pitfalls to make accurate diagnoses.14,15 Imaging
using conventional MRI is also limited because of the
low signal intensity of the tendons until relatively late in
the disease process;16 the difficulty of separating the
fibres of the supraspinatus and infraspinatus tendons;17
and anatomical variations in the biceps brachii origin,18
supraspinatus insertion,19 anterosuperior labrum,20,21 and
glenohumeral ligaments.21
Apart from any technical shortfalls in equipment, in-
formation about the diagnostic impact of costly investiga-
tions on patient management remains limited. In 2010,
Hendee and colleagues22 reported that a large number
of sophisticated imaging procedures had failed to pro-
vide information that improved patient management.
Other studies have shown that a large proportion of costly
imaging studies ordered by primary care physicians are
unnecessary and do not affect patient management.23–25
In spite of these limitations, however, the number of
advanced investigations in North America has been in-
creasing over the past decade.26–28 Eliminating unneces-
sary imaging investigations will improve health care costs
and patient safety and increase the availability of such
investigations for those who are in real need of them.
At present, there is little literature on the role of
physiotherapists in ordering imaging investigations.4,29
However, we are not aware of any literature that has
investigated the impact on patient management of diag-
nostic imaging ordered by APPs. Considering the impor-
Physiotherapy Canada, Volume 69, Number 4
tance of an APP’s role in reducing the burden on the sys-
tem and the lack of information about the use of imaging
by these health care providers for shoulder conditions,
further investigation of the subject is warranted. The
purpose of this study was therefore twofold: (1) to explore
the clinical decision making of an APP by examining the
relationship between clinical examination findings and
the reasons for ordering musculoskeletal imaging investi-
gations (e.g., plain radiographs, US, MRI, and MRA of the
shoulder) and (2) to examine the impact of diagnostic
imaging on patient management.
METHODS
Patient population
This was a prospective study of consecutive patients
with shoulder complaints, referred to an orthopaedic
shoulder specialist at a tertiary care centre. An APP with
advanced postgraduate training and experience in shoulder
examination initially examined all patients who were
referred to the clinic by their family physician or rheu-
matologist. Approval for the study was obtained from
the Research Ethics Board of the Sunnybrook Health
Sciences Centre (project no. 188–2013).
Clinical findings and clinical decision making
Information on any existing imaging was documented.
Detailed history of shoulder-related information (e.g.,
symptoms, history of injury), physical findings (e.g., muscle
atrophy, range of motion [ROM], strength testing), indica-
tions for ordering investigations, change in management,
and finally the actual management (conservative, surgical)
were documented using a standardized data collection
form. ROM was performed both actively and passively.
Reduced active flexion and external rotation in neutral
and hand behind back were documented as ‘‘yes’’ when
the patient had full passive ROM but was unable to
move through the range because of weakness. A capsular
pattern of restriction was documented as ‘‘yes’’ when
active and passive external rotation were 30 degrees or
less and active and passive flexion were limited to 100
degrees or less.30 Strength was categorized on a 5-point
scale as no weakness (5), good (4), fair (3), poor (2), and
trace (1), using manual muscle testing (MMT); this test
has established reliability and validity in asymptomatic
subjects and patients with musculoskeletal or neuro-
musculoskeletal dysfunction.31 Impingement sign was
documented as positive when either a Neer or a Hawkins
test, or both,32,33 produced pain in the subacromial area.
Atrophic changes of the rotator cuff were categorized as
none, mild, moderate, or major. Mild atrophy referred to
diffuse changes in supraspinatus, infraspinatus, or both.
Moderate changes involved visible muscle atrophy, with
depression of the muscles in the supraspinatus or infra-
spinatus fossae. Major atrophy referred to significant loss
of muscle bulk in both supraspinatus and infraspinatus
muscles.
 Razmjou et al. Impact of Radiographic Imaging of the Shoulder Joint on Patient Management: An Advanced-Practice Physical Therapist’s Approach 353

With respect to clinical decision making, the relation- Table 1 Characteristics of Sample (n ¼ 300)
ship between clinical findings and reasons for ordering
Characteristic No. (%) of participants*
the investigations was examined.
Mean age, y; range 61 (13); 21–92
Reasons for ordering investigations and outcome of Sex
investigations Male 157 (52.3)
For the purpose of this study, the indications for Female 143 (47.7)
ordering each investigation were documented on the Affected side
basis of the nature of the investigation. The Appendix Right 141 (47.0)
Left 70 (23.3)
http://utpjournals.press/doi/pdf/10.3138/ptc.2016-41PC - Friday, May 04, 2018 4:59:58 AM - University of Winnipeg IP Address:142.132.1.147

lists the indications for each investigation. Bilateral 89 (29.7)

The outcome of the investigations was documented Side examined
as (1) pretest diagnosis confirmed and (2) new diagnosis Right 191 (63.7)
relevant to patient’s symptoms added. These categories Left 109 (36.3)
were not mutually exclusive. Relevance was confirmed Dominant side
Right 281 (93.7)
only when the imaging findings explained the unresolved Left 19 (6.3)
symptomatology and matched the clinical findings of Mean duration of symptoms, mo, range 54 (84); 2–480
impingement, weakness, or instability. Previous surgery
Yes 25 (8.3)
Change in clinical management No 275 (91.7)
Management was either (1) changed or (2) not changed, Symptoms†
based on whether the type of treatment had changed Night pain 178 (59.3)
between conservative and surgical categories or within Stiffness 131 (43.7)
Weakness 107 (35.7)
each category. For example, if treatment had changed Instability 9 (3.0)
from conservative treatment to surgery or from surgery Mechanism of injury
to conservative treatment, it was considered to have Insidious 126 (42.0)
changed. Similarly, if injection had changed to physio- Traumatic 63 (21.0)
therapy within the conservative category or if rotator Repetitive 40 (13.3)
Fall 44 (14.7)
cuff decompression had changed to rotator cuff repair Direct blow 1 (0.3)
within the surgical category, management was considered Traction injury 5 (1.7)
to have changed. Other 21 (7.0)
Medication†
Statistical analysis NSAID 68 (22.7)
Descriptive statistics (number, means and SDs, range, Narcotics 33 (11.0)
percentage) were developed for all variables of interest Mild analgesics 76 (25.3)
(demographics, clinical examination findings, indications None 123 (41.0)
Injection
for ordering investigations, outcomes, change in manage- Subacromial 37 (12.3)
ment). Clinical decision making was examined by ex- Glenohumeral 8 (2.6)
ploring the relationships between clinical examination
findings and indications for ordering investigations. This *Unless otherwise indicated.
was examined by means of t-test analyses and w2 statistics † Categories overlap.
or Fisher’s exact tests for continuous and categorical NSAID ¼ non-steroidal anti-inflammatory drug.
data, respectively. Predictors of change in management
were (1) the reasons for ordering diagnostic imaging and
(2) the outcomes of the investigations. The w2 statistics clavicular or subacromial injection, and 8 (3%) patients
were used to examine these relationships. Statistical had a glenohumeral injection. The number of patients
analysis was performed using SAS, version 9.1.3 (SAS requiring surgery and the type of surgery they required
Institute, Cary, NC). Statistical results are reported using are shown in Table 2. The table shows that 83 (28%)
two-tailed p values, with significance set at p < 0.05. needed rotator cuff repair, and 67 (22%) needed rotator
cuff decompression. Superior labral tear from anterior
RESULTS posterior (SLAP) repairs, stabilization, debridement for
A total of 300 consecutive patients—143 (48%) women osteoarthritis, and shoulder replacement were less pre-
and 157 (52%) men, with a mean age of 61 (SD 13) valent, ranging from 1% to 6%. Some surgeries over-
years—were seen over a period of 12 months and were lapped—for example, some patients had both rotator cuff
followed up until their investigations had been completed. repair and acromioplasty. Rotator cuff pathology (tear and
Table 1 shows the characteristics of the sample studied. impingement syndrome) was the predominant diagnostic
Of the 300 patients, 283 (94%) received a rehabilita- category within all imaging investigations except for MRA.
tion protocol. In all, 37 (12%) patients had an acromio-
 354 Physiotherapy Canada, Volume 69, Number 4

Table 2 Summary of Final Management Categories (n ¼ 300) Table 4 Association between Both Reduced Combined Active External
Rotation and Flexion and Reduced MMT and Indication to Order Plain
Type of management No. (%) of participants Radiographs for Expected Superior Migration of Humeral Head with
Respect to Glenoid
Conservative*
Rehabilitation 283 (94.3) Indication Yes No Total
Subacromial injection 37 (12.3)
Glenohumeral joint injection 8 (2.7) Reduced combined active external rotation and flexion
Surgical* Superior migration expected 30 35 65
Rotator cuff repair 83 (27.7) Superior migration not expected 10 166 176
Rotator cuff decompression 67 (22.3) Total 40 201 241
http://utpjournals.press/doi/pdf/10.3138/ptc.2016-41PC - Friday, May 04, 2018 4:59:58 AM - University of Winnipeg IP Address:142.132.1.147

Shoulder replacement 18 (6.0) Reduced MMT*

Debridement for osteoarthritis 10 (3.3) Superior migration expected 44 21 65
Stabilization/Bankart repair 5 (1.7) Superior migration not expected 14 162 176
SLAP repair 3 (1.0) Total 58 183 241

Note: For reduced combined active external rotation, w21 ¼ 56.17; p < 0.0001.
*Categories overlap. For reduced MMT, w21 ¼ 92.70; p < 0.0001.
SLAP ¼ superior labral anterior posterior. *Categories ‘‘Good’’ and ‘‘Normal’’ were integrated and examined against the
category ‘‘Fair.’’ No data were observed in the ‘‘Poor’’ or ‘‘Trace’’ category.
MMT ¼ manual muscle testing.
Table 3 Association between Rotator Cuff Atrophy and Indication to
Order Plain Radiographs for Expected Superior Migration of Humeral Head
with Respect to Glenoid
Outcome of investigations and change in management
Rotator cuff atrophy At their initial visit with the APP, 46 (15%) patients
presented with plain radiograph reports, 46 (15%) had a
Indication None Mild Moderate Major Total
US report, and 130 (43%) had an MRI report. The APP
Superior migration expected 5 17 30 13 65 ordered 241 (80%) plain radiographs and 39 (13%) MRI
Superior migration not expected 87 71 13 3 174 and 27 (9%) US investigations. An MRA was ordered for
Total 92 88 43 16 239 only 7 (2%) patients. For details on the outcome of new
imaging investigations and change in management, see
Note: Fisher’s exact test < 0.0001; p < 0.0001. Table 5.

Clinical decision making
Clinical signs of impingement syndrome were asso-
ciated with the following indications for ordering plain
radiographs: (1) to rule out subacromial osseous pathology
(w21 ¼ 9.56, p ¼ 0.01) and (2) to confirm subacromial
osseous pathology (w21 ¼ 6.08, p ¼ 0.047). Impingement
signs were also associated with ordering US to rule out
rotator cuff or biceps pathology (w21 ¼ 7.35, p ¼ 0.026).
The results of the following clinical examination tests
were associated with ordering plain radiographs to ex-
amine the biomechanics of the glenohumeral joint for
suspected superior subluxation of the humeral head: (1)
an inability to actively flex and externally rotate the
affected arm (p < 0.0001), (2) the presence of muscle
atrophy (p < 0.0001), and (3) strength based on MMT
(p < 0.0001). The presence of muscle atrophy was also
associated with ordering US to rule out or confirm rotator
cuff or biceps pathology (w21 ¼ 6.30, p ¼ 0.01). Tables 3
and 4 show the frequency of observations for indications
to order plain radiographs and clinical tests. Specific
clinical signs of impingement syndrome or rotator cuff
weakness were not associated with indications to order
MRI, and the number of MRA investigations was not
sufficient for statistical analysis.
Plain radiographs
The APP ordered plain radiographs for 241 patients as
the first line of investigation. Of those, 13 (5.4%) patients
had repeat plain radiographs because the previous radio-
graphs were either of poor quality or had outdated or
incomplete views.
Outcome: Although clinical diagnosis was confirmed
in 227 (94%) patients, 171 (71%) patients had a new rele-
vant diagnosis.
Change in management: Predictors of change in
management were the indication for ordering plain radio-
graphs to examine the biomechanics of the glenohumeral
joint (w21 ¼ 8.66, p ¼ 0.003) and establishing a new diag-
nosis (w21 ¼ 88.39, p < 0.0001).
Ultrasound
The APP ordered an US for 27 patients. Six patients
had a repeat US as a result of an outdated report, poor
quality report, or findings not correlating with clinical
findings at the time of assessment. Four patients did not
complete their US.
Outcome: Although pre-US clinical diagnosis was con-
firmed in 14 patients, 17 received a new diagnosis.
Change in management: A predictor of change in
management after US was finding a new diagnosis (w21 ¼
16.00, p < 0.0001).
 Razmjou et al. Impact of Radiographic Imaging of the Shoulder Joint on Patient Management: An Advanced-Practice Physical Therapist’s Approach 355

Table 5 Number of Ordered Investigations (n ¼ 300) MRI

Imaging investigations No. (%)
The APP ordered a new MRI for 39 (13%) patients. Six
of them had a repeat MRI because the previous MRI was
Plain radiographs (completed: 241) outdated, and 28 completed their MRI.
Total number ordered 241 (80.3)
Reordered 13 (5.4) Outcome: Outcomes were examined in 28 patients
Indication* who had completed their MRI investigation; 22 (79%) had
Pre-surgical 49 (20.3) their pre-MRI clinical diagnosis confirmed, and 17 (61%)
R/O osseous pathology 136 (56.4)
Confirm osseous pathology 46 (19.1) patients received a new diagnosis.
Examine biomechanics of the glenohumeral joint 48 (19.9) Change in management: Finding a new diagnosis
http://utpjournals.press/doi/pdf/10.3138/ptc.2016-41PC - Friday, May 04, 2018 4:59:58 AM - University of Winnipeg IP Address:142.132.1.147

R/O visible instability 2 (0.8) after MRI investigation was correlated with change in
R/O other pathologies 10 (4.1)
Outcome* management (w21 ¼ 11.00, p < 0.0009).
Pre-investigation diagnosis confirmed 227 (94.1)
New diagnosis added 171 (70.9) Magnetic resonance arthrogram
Management The APP ordered only seven MRA investigations. One
Changed 136 (56.4) patient (<1%) had this investigation to confirm a labral
Not changed 105 (43.6)
Pre-surgical 24/105 (22.8) pathology; the other six required an MRA to rule out
US (completed: 23) labral pathology. Two patients had both rotator cuff and
Total number ordered 27 (9.0) labral pathology. Because of the small number of MRA
Reordered 6 (22.2)
Not completed 4 (14.8) investigations, the relationship between management and
Indication* indications could not be statistically assessed.
Pre-surgical 7 (30.4)
R/O RC/biceps pathology 8 (34.7) DISCUSSION
Confirm RC/biceps pathology 4 (17.4)
Establish severity of RC/biceps pathology 5 (21.7) At present, the American College of Radiology (ACR)
Outcome* has proposed some criteria for ordering investigations
Pre-investigation diagnosis confirmed 14 (60.9) for shoulder pathology.34 According to ACR guidelines,
New diagnosis added 17 (73.9)
Management radiographs should be the first line of investigation for
Changed 18 (78.3) patients with acute shoulder pain. In patients with normal
Not changed 5 (21.7) radiographs for whom symptoms persist, MRI (which the
Pre-surgical 1/5 (20)
MRI (completed: 28) guidelines consider to be ‘‘usually appropriate’’) or US
Total number ordered 39 (13.0) (‘‘may be appropriate’’) is then considered.34 In the case
Reordered 6 (15.4) of abnormal radiographs, such as the presence of sub-
Not completed 11 (28.2)
Indication* acromial osteophytes or abnormal rotator cuff examina-
Pre-surgical 18 (64.3) tion, US and MRI are considered ‘‘usually appropriate.’’34
R/O RC/biceps pathology 1 (3.6) Although the ACR’s appropriateness criteria that apply to
Confirm RC/biceps pathology 4 (14.3)
Establish severity of RC/biceps pathology 5 (17.8) acute shoulder conditions were valuable in our sample,
R/O labral pathology 0 (0.0) better guidelines are needed for chronic or age-related
Confirm labral pathology 0 (0.0) conditions because these conditions have more complex
Other 2 (7.1)
Outcome (n ¼ 28)* symptoms and a more complex management algorithm.
Pre-investigation diagnosis confirmed 22 (78.6) In the present study, there was a statistically signifi-
New diagnosis added 17 (60.7) cant relationship between clinical examination findings
Management (n ¼ 28)
Changed 15 (53.5) and the ordering of plain radiographs and US. We found
Not changed 13 (46.4) no relationship between clinical findings and indications
Pre-surgical 8/13 (61.5) for ordering MRI, which may be related to the diverse
MRA (completed: 7)
Total number ordered 7 (2.3) clinical presentation of patients with impingement syn-
Reordered 0 (0.0) drome or small rotator cuff tears and the small number
Indication* of cases in each category (see Tables 3 and 4).
Pre-surgical 1 (14.3)
R/O RC/biceps pathology 1 (14.3) The purpose of plain radiographs in a tertiary care
Confirm RC/biceps pathology 1 (14.3) setting is to either rule out or confirm enthesopathic
R/O labral pathology 5 (71.4) changes, subacromial osseous pathologies, subchondral
Confirm labral pathology 1 (14.3)
Outcome (n ¼ 7) cyst formation, and so forth, all of which are associated
Pre-investigation diagnosis confirmed 6 (85.7) with clinical signs of impingement or rotator cuff disease.
New diagnosis added 1 (14.3) Superior subluxation of the humeral head in relation to
Management (n ¼ 7)
Changed 5 (71.4) the glenoid seen on plain radiographs is also a common
Not changed 2 (28.5) finding in patients with muscle atrophy and weak-
Pre-surgical 1 (14.3) ness secondary to large or massive tears of the rotator
cuff.35,36 Superior subluxation of the humeral head reduces
*Categories overlap.
the acromion–humeral distance (AHD), which will lead to
R/O ¼ rule out; RC ¼ rotator cuff; US ¼ ultrasound; MRI ¼ magnetic
resonance imaging; MRA ¼ magnetic resonance arthrogram
 356 Physiotherapy Canada, Volume 69, Number 4

cuff tear arthropathy and a need for shoulder joint replace-
ment because the subchondral bone weakens progres-
sively with the impaction of the humeral head against
the acromion.37,38
Nazarian and colleagues39 noted that plain radiographs
help to rule out an alteration of the position of the
humeral head in relation to the glenoid. Similarly, Moosi-
kawan and colleagues40 found that decreased opacity with
superior subluxation of the humeral head and secondary
http://utpjournals.press/doi/pdf/10.3138/ptc.2016-41PC - Friday, May 04, 2018 4:59:58 AM - University of Winnipeg IP Address:142.132.1.147
versely, none of the specific indication categories for
ordering US or MRI investigations were correlated with
change in clinical management. One reason may be the
small number of US (n ¼ 23) and MRI (n ¼ 28) investiga-
tions ordered, which made it difficult to detect a statisti-
cally significant relationship. A lack of relationship be-
tween clinical findings and indications for ordering MRIs
is related to the small number of cases in each category
(see Tables 3 and 4) and the fact that patients with im-

degenerative arthritis of the glenohumeral joint are in- pingement syndrome or small rotator cuff tears have a
dicators of cuff pathology. The presence of advanced diverse clinical presentation.
superior subluxation of the humeral head usually indi- The consistent finding of this study was the value of
cates poor feasibility (i.e., ability to repair) for rotator a relevant new diagnosis as a predictor of change in
cuff tendons; in certain cases, this can result in switching clinical management, regardless of the investigation used.
the type of surgery from repair to reverse arthroplasty. In The complex clinical decision-making process used by
a study of 60 patients, Dwyer and colleagues41 found a the examiner highlights the importance of the clinician’s
relationship between the degree of superior subluxation intuition in forming a proper pretest probability that
of the humeral head and the reparability of the rotator is based on knowledge of the literature, experience, and
cuff tendons at surgery. Similarly, in a study of 109 plain exposure to similar cases.
radiographs by Goutallier and colleagues,42 the authors
Role of Advanced-Practice Physical Therapists
reported that an AHD of less than 6 millimetres, secondary
The increasing evidence demonstrating appropriate
to superior subluxation of the humeral head, was asso-
clinical decision making by physical therapists for using
ciated with difficulty in obtaining a full surgical repair.
diagnostic imaging is encouraging. A study comparing
These authors noted that, in advanced cases—that is,
the care administered by physical therapists with that
cases in which the AHD distance was less than 4 milli-
administered by orthopaedic surgeons in the primary
metres—more costly investigations such as MRI were
management of musculoskeletal problems determined
not necessary because the surgical repair was unlikely to
that the physical therapists were more cost effective, with
be feasible.42
no compromise in clinical outcomes.4 Reductions of as
The presence of positive impingement signs was asso-
much as 50% in the use of diagnostic imaging have
ciated with ordering US to rule out rotator cuff or biceps
been reported in other studies when physical therapists
pathology, which suggests that US may be a more effi-
working in direct access settings have privileges for
cient modality in the APP clinical setting for excluding
ordering the procedure.4,49–51 In one study that examined
soft tissue pathologies because of its nearly equivalent
agreement on ordering investigations for patients with
accuracy with MRI for rotator cuff tears,39,43–47 greater
shoulder conditions seen independently, an APP and
safety, better availability, and lower cost.48 Therefore, in
an orthopaedic surgeon agreed on 97 of 103 patients for
the absence of significant clinical signs of a full-thickness
plain radiographs and 91 of 100 patients for MRI.1 In
tear, US is an efficient investigation in candidates for
a large randomized controlled trial of patients with
rotator cuff decompression surgery (e.g., lateral resection
musculoskeletal conditions that compared post-fellowship,
of the clavicle or acromioplasty). However, MRI is recom-
junior orthopaedic surgeons with specially trained physical
mended for surgical planning in older patients with asso-
therapists, the junior surgeons ordered a significantly
ciated osseous degenerative changes, atrophic changes,
higher number of plain radiographs (p < 0.0001).4
and weakness, which usually indicate more complex
In the present study, the frequency of ordering imag-
tears that have failed conservative management and are
ing varied from 80% for plain radiographs to 13% for
required for surgical planning. Figure 1 shows a flow-
MRI, 9% for US, and 2% for MRA. Of note is the fact that
chart for managing rotator cuff pathology used by APPs
49 (20%) of the 241 patients were surgical candidates
who manage chronic shoulder conditions. This flowchart
who had required recent radiographs for the purpose of
is based on the results of the present study as well as the
surgery. Only 46 (15%) of 300 patients had previous plain
clinical expertise of the investigators.
radiographs, and the high rate of plain radiographs (241;
In terms of indications for ordering diagnostic investiga-
80%) ordered by the APP was related to a higher fre-
tions that can be used for clinical management, previous
quency of chronic or complex conditions seen in the
studies23,24 have shown that documenting a reason for
tertiary care centre. Despite the fact that an MRI can
ordering a costly investigation encourages clinicians to
accurately detect soft tissue injuries, it is not the best
do so judiciously. In the present study, ordering plain
modality for assessing bony pathology (i.e., bony de-
radiographs to examine glenohumeral biomechanics
generative changes or subacromial osteophytes may not
had an effect on clinical management decisions. Con-
 Razmjou et al. Impact of Radiographic Imaging of the Shoulder Joint on Patient Management: An Advanced-Practice Physical Therapist’s Approach
http://utpjournals.press/doi/pdf/10.3138/ptc.2016-41PC - Friday, May 04, 2018 4:59:58 AM - University of Winnipeg IP Address:142.132.1.147
Figure 1 Decision flowchart for investigating chronic rotator cuff pathology.
MRI ¼ magnetic resonance imaging; US ¼ ultrasound; OA ¼ osteoarthritis; ACJ ¼ acromioclavicular joint.
cause clinical symptoms) or the biomechanics of the
shoulder joint (i.e., the images are taken with the patient
lying down, a position that may affect the accuracy of
the AHD measurement). The much lower rate of use
of MRI for soft tissue injuries shows the importance of
a clinician’s experience and education in performing
an appropriate, focused clinical examination, the most
fundamental tool in the field of diagnosis.
Factors that may lead to inappropriate use of diagnostic
imaging are numerous: medical liability issues, econom-
ically motivated self-referrals, patient demands, and dif-
ferences in practice style. It is critical that the medical
community develop better guidelines for ordering diag-
nostic imaging investigations such as MRI and MRA in
subacute and chronic cases, not only because of the
current fiscally constrained environment but also because
of the shift to team-based models of care, which use non-
physicians such as extended-role physical therapists to
improve access to quality care. In our study, we were
able to establish the importance of plain radiographs as
the first line of investigation, particularly their impact
357
on finding a new diagnosis and guiding clinical manage-
ment in patients with suspected rotator cuff pathologies.
There are two limitations to this study. First, it was
conducted in an academic tertiary care centre, which may
affect the generalizability of our findings. Also, our results
are not generalizable to patients with acute symptoms
or patients whose demographic characteristics or clinical
presentations are different from those of our sample.
Future studies are required to provide APPs with more
specific guidelines for ordering costly investigations in
the presence of reduced AHD.
CONCLUSION
Skilled, extended-role physical therapists rely on history
and clinical examination without overusing costly diag-
nostic imaging. In the present study, a small percentage
of patients required costly investigations such as MRI
and MRA. Abnormal biomechanics of the glenohumeral
joint on plain radiographs correlated with clinical find-
ings of rotator cuff pathology and had an impact on
the clinical management of patients. In addition, finding
a new diagnosis was the most important indicator of
 358
change in management, regardless of the type of diag-
nostic imaging investigations ordered.
KEY MESSAGES
What is already known on this topic
The emerging literature has shown the importance of
the role of advanced-practice physical therapists in re-
ducing the burden on the health care system. However,
studies on their role in ordering costly diagnostic imaging
http://utpjournals.press/doi/pdf/10.3138/ptc.2016-41PC - Friday, May 04, 2018 4:59:58 AM - University of Winnipeg IP Address:142.132.1.147
are sparse, and evidence of the impact of these imaging
investigations on patient management is lacking.
What this study adds
The present study highlights the importance of plain
radiographs as the first line of investigation in patients
with suspected rotator cuff pathology. Indications for
more costly imaging investigations should be based on
clinical examination findings and the potential need for
further conservative management or surgery. To change
patient management, imaging should ultimately improve
the clinician’s intuition by adding new information to
what is already known from the clinical examination.
REFERENCES
1. Razmjou H, Robarts S, Kennedy D, et al. Evaluation of an advanced-
practice physical therapist in a specialty shoulder clinic: diagnostic
agreement and effect on wait times. Physiother Can. 2013;65(1):46–
55. http://dx.doi.org/10.3138/ptc.2011-56. Medline:24381382
2. Moore JH, Goss DL, Baxter RE, et al. Clinical diagnostic accuracy
and magnetic resonance imaging of patients referred by physical
therapists, orthopaedic surgeons, and nonorthopaedic providers.
J Orthop Sports Phys Ther. 2005;35(2):67–71. http://dx.doi.org/
10.2519/jospt.2005.35.2.67. Medline:15773564
3. Kennedy DM, Robarts S, Woodhouse L. Patients are satisfied with
advanced practice physiotherapists in a role traditionally performed
by orthopaedic surgeons. Physiother Can. 2010;62(4):298–305.
http://dx.doi.org/10.3138/physio.62.4.298. Medline:21886368
4. Daker-White G, Carr AJ, Harvey I, et al. A randomised controlled
trial. Shifting boundaries of doctors and physiotherapists in
orthopaedic outpatient departments. J Epidemiol Community
Health. 1999;53(10):643–50. http://dx.doi.org/10.1136/
jech.53.10.643. Medline:10616677
5. Desmeules F, Roy JS, MacDermid JC, et al. Advanced practice
physiotherapy in patients with musculoskeletal disorders: a
systematic review. BMC Musculoskelet Disord. 2012;13:107. http://
dx.doi.org/10.1186/1471-2474-13-107.
6. Desmeules F, Toliopoulos P, Roy JS, et al. Validation of an advanced
practice physiotherapy model of care in an orthopaedic outpatient
clinic. BMC Musculoskelet Disord. 2013;14:162. http://dx.doi.org/
10.1186/1471-2474-14-162.
7. Railhac JJ, Sans N, Rigal A, et al. [Strict anteroposterior radiography
of the shoulder: value of the assessment of rotator cuff tears].
J Radiol. 2001;82(9 Pt 1):979–85. Medline:11591925
8. Nové-Josserand L, Boulahia A, Levigne C, et al. [Coraco-humeral
space and rotator cuff tears]. Rev Chir Orthop Reparatrice Appar
Mot. 1999;85(7):677–83. Medline:10612131
9. Jankauskas L, Rüdiger HA, Pfirrmann CW, et al. Loss of the sclerotic
line of the glenoid on anteroposterior radiographs of the shoulder:
a diagnostic sign for an osseous defect of the anterior glenoid rim.
J Shoulder Elbow Surg. 2010;19(1):151–6. http://dx.doi.org/10.1016/
j.jse.2009.04.013. Medline:19556149
Physiotherapy Canada, Volume 69, Number 4
10. Dinnes J, Loveman E, McIntyre L, et al. The effectiveness of
diagnostic tests for the assessment of shoulder pain due to soft
tissue disorders: a systematic review. Health Technol Assess.
2003;7(29):iii, 1–166. http://dx.doi.org/10.3310/hta7290.
Medline:14567906
11. Razmjou H, Fournier-Gosselin S, Christakis M, et al. Accuracy of
magnetic resonance imaging in detecting biceps pathology in
patients with rotator cuff disorders: comparison with arthroscopy.
J Shoulder Elbow Surg. 2016;25(1):38–44. Medline:26271551
12. Teefey SA, Hasan SA, Middleton WD, et al. Ultrasonography of the
rotator cuff. A comparison of ultrasonographic and arthroscopic
findings in one hundred consecutive cases. J Bone Joint Surg Am.
2000;82(4):498–504. http://dx.doi.org/10.2106/00004623-200004000-
00005. Medline:10761940
13. Phillips JC, Cook C, Beaty S, et al. Validity of noncontrast magnetic
resonance imaging in diagnosing superior labrum anterior-posterior
tears. J Shoulder Elbow Surg. 2013;22(1):3–8. http://dx.doi.org/
10.1016/j.jse.2012.03.013. Medline:22938789
14. Gaitini D. Shoulder ultrasonography: performance and common
findings. J Clin Imaging Sci. 2012;2(1):38. http://dx.doi.org/10.4103/
2156-7514.99146. Medline:22919552
15. Le Corroller T, Cohen M, Aswad R, et al. Sonography of the painful
shoulder: role of the operator’s experience. Skeletal Radiol.
2008;37(11):979–86. http://dx.doi.org/10.1007/s00256-008-0539-z.
Medline:18651142
16. Du J, Chiang AJ, Chung CB, et al. Orientational analysis of the
Achilles tendon and enthesis using an ultrashort echo time
spectroscopic imaging sequence. Magn Reson Imaging.
2010;28(2):178–84. http://dx.doi.org/10.1016/j.mri.2009.06.002.
Medline:19695811
17. Clark JM, Harryman DT II. Tendons, ligaments, and capsule of the
rotator cuff. Gross and microscopic anatomy. J Bone Joint Surg Am.
1992;74(5):713–25. http://dx.doi.org/10.2106/00004623-199274050-
00010. Medline:1624486
18. Marcon GF, Macedo TA. Artifacts and pitfalls in shoulder magnetic
resonance imaging. Radiol Bras. 2015;48(4):242–8. http://dx.doi.org/
10.1590/0100-3984.2013.0006. Medline:26379323
19. Mochizuki T, Sugaya H, Uomizu M, et al. Humeral insertion of the
supraspinatus and infraspinatus. New anatomical findings regarding
the footprint of the rotator cuff. Surgical technique. J Bone Joint Surg
Am. 2009;91(Suppl 2 Pt 1):1–7. http://dx.doi.org/10.2106/
JBJS.H.01426. Medline:19255195
20. Beltran J, Bencardino J, Padron M, et al. The middle glenohumeral
ligament: normal anatomy, variants and pathology. Skeletal Radiol.
2002;31(5):253–62. http://dx.doi.org/10.1007/s00256-002-0492-1.
Medline:11981601
21. Fitzpatrick D, Walz DM. Shoulder MR imaging normal variants and
imaging artifacts. Magn Reson Imaging Clin N Am. 2010;18(4):615–
32. http://dx.doi.org/10.1016/j.mric.2010.07.006. Medline:21111969
22. Hendee WR, Becker GJ, Borgstede JP, et al. Addressing
overutilization in medical imaging. Radiology. 2010;257(1):240–5.
http://dx.doi.org/10.1148/radiol.10100063. Medline:20736333
23. Wylie JD, Crim JR, Working ZM, et al. Physician provider type
influences utilization and diagnostic utility of magnetic resonance
imaging of the knee. J Bone Joint Surg Am. 2015;97(1):56–62. http://
dx.doi.org/10.2106/JBJS.N.00065. Medline:25568395
24. Lehnert BE, Bree RL. Analysis of appropriateness of outpatient CT
and MRI referred from primary care clinics at an academic medical
center: how critical is the need for improved decision support? J Am
Coll Radiol. 2010;7(3):192–7. http://dx.doi.org/10.1016/
j.jacr.2009.11.010. Medline:20193924
25. Freeman R, Khanna S, Ricketts D. Inappropriate requests for
magnetic resonance scans of the shoulder. Int Orthop.
2013;37(11):2181–4. http://dx.doi.org/10.1007/s00264-013-1968-4.
Medline:23793463
 Razmjou et al. Impact of Radiographic Imaging of the Shoulder Joint on Patient Management: An Advanced-Practice Physical Therapist’s Approach
26. Smith-Bindman R, Miglioretti DL, Larson EB. Rising use of
diagnostic medical imaging in a large integrated health system.
Health Aff (Millwood). 2008;27(6):1491–502. http://dx.doi.org/
10.1377/hlthaff.27.6.1491. Medline:18997204
27. ACIL Tasman. Funding arrangements for diagnostic imaging
services. an international literature review [Internet]. Canberra:
Department of Health and Ageing; 2010 [cited 2017 Jan 10]. Available
from: http://www.thescannermagazine.com/images/pdfs/pdf16.pdf
28. Canadian Association of Radiologists. Appropriateness projects,
Manitoba Demonstration Project in Physician Demand-Side Control
for Diagnostic Imaging—full report 2008 [Internet]. Ottawa:
http://utpjournals.press/doi/pdf/10.3138/ptc.2016-41PC - Friday, May 04, 2018 4:59:58 AM - University of Winnipeg IP Address:142.132.1.147
The Association; 2008 [cited 2017 Jan 10]. Available from: http://
www.car.ca/en/about/reports/appropriateness.aspx.
29. Ball ST, Walton K, Hawes S. Do emergency department
physiotherapy practitioner’s, emergency nurse practitioners and
doctors investigate, treat and refer patients with closed
musculoskeletal injuries differently? Emerg Med J. 2007;24(3):185–8.
http://dx.doi.org/10.1136/emj.2006.039537. Medline:17351223.
30. Razmjou H, Henry P, Costa G, et al. Effect of arthroscopic rotator
cuff surgery in patients with preoperative restricted range of motion.
BMC Musculoskelet Disord. 2016;17(1):99. http://dx.doi.org/
10.1186/s12891-016-0956-4. Medline:26911157
31. Cuthbert SC, Goodheart GJ Jr. On the reliability and validity of
manual muscle testing: a literature review. Chiropr Osteopat.
2007;15(1):4. http://dx.doi.org/10.1186/1746-1340-15-4.
Medline:17341308
32. Neer CS II. Anterior acromioplasty for the chronic impingement
syndrome in the shoulder. 1972. J Bone Joint Surg Am.
2005;87(6):1399. http://dx.doi.org/10.2106/00004623-200506000-
00031. Medline:15930554
33. Hawkins RJ, Kennedy JC. Impingement syndrome in athletes. Am J
Sports Med. 1980;8(3):151–8. http://dx.doi.org/10.1177/
036354658000800302. Medline:7377445
34. Wise JN, Daffner RH, Weissman BN, et al. ACR Appropriateness
Criteria2 on acute shoulder pain. J Am Coll Radiol. 2011;8(9):602–9.
http://dx.doi.org/10.1016/j.jacr.2011.05.008. Medline:21889746
35. Kaneko K, De Mouy EH, Brunet ME. Massive rotator cuff tears.
Screening by routine radiographs. Clin Imaging. 1995;19(1):8–11.
http://dx.doi.org/10.1016/0899-7071(94)00024-7. Medline:7895205
36. Weiner DS, Macnab I. Superior migration of the humeral head.
A radiological aid in the diagnosis of tears of the rotator cuff. J Bone
Joint Surg Br. 1970;52(3):524–7. Medline:5455085
37. Hamada K, Fukuda H, Mikasa M, et al. Roentgenographic findings in
massive rotator cuff tears. A long-term observation. Clin Orthop
Relat Res. 1990;(254):92–6. Medline:2323152
38. Neer CS II, Craig EV, Fukuda H. Cuff-tear arthropathy. J Bone Joint
Surg Am. 1983;65(9):1232–44. http://dx.doi.org/10.2106/00004623-
198365090-00003. Medline:6654936
39. Nazarian LN, Jacobson JA, Benson CB, et al. Imaging algorithms for
evaluating suspected rotator cuff disease: Society of Radiologists in
Ultrasound consensus conference statement. Radiology.
359
2013;267(2):589–95. http://dx.doi.org/10.1148/radiol.13121947.
Medline:23401583
40. Moosikasuwan JB, Miller TT, Burke BJ. Rotator cuff tears: clinical,
radiographic, and US findings. Radiographics. 2005;25(6):1591–607.
http://dx.doi.org/10.1148/rg.256045203. Medline:16284137
41. Dwyer T, Razmjou H, Henry P, et al. Association between pre-
operative magnetic resonance imaging and reparability of large and
massive rotator cuff tears. Knee Surg Sports Traumatol Arthrosc.
2015;23(2):415–22. http://dx.doi.org/10.1007/s00167-013-2745-z.
Medline:24170190
42. Goutallier D, Le Guilloux P, Postel JM, et al. Acromio humeral
distance less than six millimeter: its meaning in full-thickness
rotator cuff tear. Orthop Traumatol Surg Res. 2011;97(3):246–51.
http://dx.doi.org/10.1016/j.otsr.2011.01.010. Medline:21459063
43. Roy JS, Braen C, Leblond J, et al. Diagnostic accuracy of
ultrasonography, MRI and MR arthrography in the characterisation
of rotator cuff disorders: a systematic review and meta-analysis. Br J
Sports Med. 2015;49:1316–28. http://dx.doi.org/10.1136/bjsports-
2014-094148. Medline:25677796
44. de Jesus JO, Parker L, Frangos AJ, et al. Accuracy of MRI, MR
arthrography, and ultrasound in the diagnosis of rotator cuff tears:
a meta-analysis. AJR Am J Roentgenol. 2009;192(6):1701–7. http://
dx.doi.org/10.2214/AJR.08.1241. Medline:19457838
45. Kim HM, Dahiya N, Teefey SA, et al. Relationship of tear size and
location to fatty degeneration of the rotator cuff. J Bone Joint Surg
Am. 2010;92(4):829–39. http://dx.doi.org/10.2106/JBJS.H.01746.
Medline:20360505
46. Kavanagh EC, Koulouris G, Parker L, et al. Does extended-field-of-
view sonography improve interrater reliability for the detection of
rotator cuff muscle atrophy? AJR Am J Roentgenol. 2008;190(1):27–
31. http://dx.doi.org/10.2214/AJR.07.2716. Medline:18094290
47. Khoury V, Cardinal E, Brassard P. Atrophy and fatty infiltration of the
supraspinatus muscle: sonography versus MRI. AJR Am J
Roentgenol. 2008;190(4):1105–11. http://dx.doi.org/10.2214/
AJR.07.2835. Medline:18356462
48. Parker L, Nazarian LN, Carrino JA, et al. Musculoskeletal imaging:
Medicare use, costs, and potential for cost substitution. J Am Coll
Radiol. 2008;5(3):182–8. http://dx.doi.org/10.1016/j.jacr.2007.07.016.
Medline:18312965
49. Greathouse DG, Schreck RC, Benson CJ. The United States Army
physical therapy experience: evaluation and treatment of patients
with neuromusculoskeletal disorders. J Orthop Sports Phys Ther.
1994;19(5):261–6. http://dx.doi.org/10.2519/jospt.1994.19.5.261.
Medline:8199619
50. James JJ, Abshier JD. The primary evaluation of musculoskeletal
disorders by the physical therapist. Mil Med. 1981;146(7):496–9.
Medline:6116210
51. James JJ, Stuart RB. Expanded role for the physical therapist.
Screening musculoskeletal disorders. Phys Ther. 1975;55(2):121–31.
Medline:124877
 360 Physiotherapy Canada, Volume 69, Number 4

APPENDIX: INDICATIONS FOR ORDERING IMAGING INVESTIGATIONS

Plain radiographs MRI

Pre-surgical Pre-surgical
R/O subacromial osseous pathology R/O RC/biceps pathology
Confirm subacromial osseous pathology Confirm RC/biceps pathology
Examine biomechanics of the glenohumeral joint Establish severity of RC/biceps pathology
R/O visible instability R/O labral pathology
R/O other pathologies Confirm labral pathology
http://utpjournals.press/doi/pdf/10.3138/ptc.2016-41PC - Friday, May 04, 2018 4:59:58 AM - University of Winnipeg IP Address:142.132.1.147

Other
Ultrasound
Pre-surgical MRA
R/O RC/biceps pathology Pre-surgical
Confirm RC/biceps pathology R/O RC/biceps pathology
Establish severity of RC/biceps pathology Confirm RC/biceps pathology
R/O labral pathology
Confirm labral pathology

R/O ¼ rule out; RC ¼ rotator cuff; MRI ¼ magnetic resonance imaging; MRA ¼ magnetic resonance arthrogram.