If you’re over 40 and have shoulder pain, there’s a good chance an MRI scan would show what doctors call a “rotator cuff abnormality.” But new research suggests that finding alone may not explain why your shoulder hurts.

A new study published in JAMA Internal Medicine found that nearly all adults over age 40 have some form of rotator cuff damage on MRI — even those with no shoulder pain at all. The findings are prompting experts to urge caution when interpreting imaging results and to emphasize a more comprehensive approach to diagnosis and treatment.

For patients, this can be confusing. If nearly everyone over 40 has some degree of rotator cuff damage on MRI, how can someone know whether that abnormality is actually causing their pain?

“That is a great question,” responds Anthony Miniaci, M.D., an orthopedic surgeon and deputy chief medical executive of Baptist Health Orthopedic Care. “Even though rotator cuff abnormalities are common findings on imaging studies, it is only one piece of the puzzle.”

What Is the Rotator Cuff?

The rotator cuff is a group of four muscles and tendons that stabilize the shoulder and allow you to lift and rotate your arm. Over time, these tendons can undergo wear and tear.

When shoulder pain develops, doctors often order magnetic resonance imaging (MRI), a detailed scan that uses magnets and radio waves to visualize soft tissues. MRIs can detect:

• Tendinopathy: Degeneration or irritation of a tendon
• Partial-thickness tears: Tears affecting part of the tendon
• Full-thickness tears: Complete tears through the tendon

These findings are commonly assumed to be the source of shoulder pain. However, the new study challenges that assumption.

What the Study Found

Researchers in Finland examined 602 adults between the ages of 41 and 76. Participants underwent shoulder examinations and high-resolution (3-Tesla) MRIs of both shoulders. They were also asked whether they had experienced shoulder pain or difficulty using their shoulder in the previous week.

The results were striking:

• 99 percent of participants had at least one rotator cuff abnormality.
• 96 percent of shoulders without pain showed abnormalities.
• 98 percent of painful shoulders also showed abnormalities.

Researchers concluded that abnormal MRI findings were almost universal — regardless of whether someone had symptoms.

The most common issue was partial-thickness tears (62 percent), followed by tendinopathy (25 percent) and full-thickness tears (11 percent). While full-thickness tears were slightly more common in painful shoulders, that difference disappeared after researchers adjusted for age and other factors. Abnormalities increased with age but were equally common in men and women.

When MRI Findings Don’t Match the Symptoms

Dr. Miniaci emphasizes that the shoulder is a complex joint with multiple potential “pain generators.”

“There are many pain generators in the shoulder, so one has to carefully evaluate the symptoms and physical findings,” Dr. Miniaci says. “Correlating the history of symptoms and disability that the patient is having with physical examination findings, confirmed with MRI or radiologic findings, is key to determining the exact source of the pain generation.”

Nonetheless, MRI remains a powerful diagnostic tool. It offers detailed images of soft tissues and can confirm structural damage. But experts say its findings must be interpreted in context.

The Value — and Limits — of MRI

“Although MRI abnormalities are not uncommon, especially as we age, correlation with the symptoms and physical examination is again key to making the full diagnosis,” Dr. Miniaci explains. “The MRI confirms that there has pathology in the area where one is concerned about some issues.”

In many cases, MRI findings simply reinforce what a clinician already suspects based on a patient’s history and physical exam. “Certain tears of a variety of different structures really only confirm what the diagnosis may be,” he says.

This is particularly relevant for people with atraumatic shoulder pain—pain that develops gradually rather than from a specific injury like a fall. In such cases, MRI findings may not clearly distinguish between age-related changes and the true cause of discomfort.

Do You Really Need an MRI?

Given the study’s findings, some patients may wonder whether an MRI is necessary at all.

“Again, an MRI confirms a history and physical examination and presumed diagnosis,” Dr. Miniaci said. “It also allows evaluation of all of the other structures within the joint to see if there are any other potential causes of pain.”

Imaging can be especially important when surgery is being considered. “If it is pre-surgical, [MRI] allows one to assure that all of the pathology that has been reported and visualized on the MRI is evaluated and treated as necessary at the time of surgery,” he explains.

However, many cases of shoulder pain can be initially managed without advanced imaging, particularly if symptoms are mild to moderate and there is no history of significant trauma.

Does MRI Change Treatment?

In many instances, MRI results confirm a diagnosis and the planned course of treatment. But there are situations in which imaging findings can alter management.

“More often than not, the MRI mainly confirms the diagnosis and treatment plan,” Dr. Miniaci says. “There are certain situations where the MRI can change the management of the patient.”

With rotator cuff tears, for example, “the size and complexity and chronicity of the tear all impact the type of treatment that will be chosen and potentially change the operative procedure,” he notes.

This means that while minor tears may be treated conservatively, larger or more complex tears could require different surgical techniques.

However, a tear appearing on the MRI does not necessarily mean that surgery is required.

“Not everybody that has a rotator cuff tear necessarily has pain or needs to have an operation,” said Dr. Miniaci. “Many patients who do have a tear can respond to non-surgical management in getting rid of their pain and improving their function, even if the tear remains in place and is not repaired.”

Surgery vs. Non-Surgical Treatment

The study’s findings also raise concerns about over-reliance on imaging that could lead to unnecessary procedures. Experts say conservative treatment should usually be the first step.

“Many patients with shoulder pain related to the rotator cuff will benefit or have the symptoms resolved with a good course of physical therapy and anti-inflammatory medication,” Dr. Miniaci said. “When a patient presents, this is likely the first course of management.”

If symptoms persist, more invasive options may be considered. “If this fails, then we can proceed to more invasive techniques, including injection therapies and eventually surgical management,” he says.

Still, surgery carries inherent risks. “The risks of surgery are real and should not be minimized,” Dr. Miniaci cautions. “Therefore, most patients should undergo conservative management prior to considering a surgical procedure.”

Strengthening and Prevention

For those looking to reduce shoulder pain or prevent symptoms from worsening, targeted exercises can help.

“There are excellent shoulder strengthening exercises available both as home programs or directly with physical therapy,” Dr. Miniaci says. He recommends reputable resources such as The American Shoulder and Elbow Surgeons (ASES) and the American Academy of Orthopaedic Surgeons (AAOS), which offer exercise programs designed for patients with shoulder issues.

Strengthening the surrounding muscles, improving flexibility, and modifying activities can often improve function and decrease discomfort—without the need for surgery.

The Study’s Bottom Line

While imaging remains an important diagnostic tool, it should not be viewed in isolation, the new research concludes. A careful physical examination, a detailed discussion of symptoms, and an understanding of how pain affects daily activities remain central to identifying the true cause of shoulder discomfort, Dr. Miniaci emphasizes

Learn about world-class orthopedic expertise and advanced services at Baptist Health Orthopedic Care.