For the millions of adults who develop shoulder pain each year, the instinct to order an MRI or pursue aggressive treatment may be doing more harm than good. A new clinical review published in JAMA Internal Medicine makes the case that most non-traumatic shoulder pain — affecting an estimated 16% of adults annually — can and should be managed conservatively, with education, activity modification, symptom relief, and watchful waiting.

The review recommends using the broader term "subacromial pain" rather than specific diagnoses like rotator cuff tendinopathy or impingement syndrome, which are inconsistently defined. Imaging frequently detects structural changes that are also present in pain-free individuals, making it an unreliable guide to treatment in the absence of red flags.

Key Takeaways:

• Imaging is only warranted when red flags are present (e.g., fever, trauma, neurologic findings, significant weakness, or failure to improve)
• X-ray is the appropriate first imaging step; MRI should be reserved for confirming a suspected diagnosis
• Topical NSAIDs are a reasonable first-line medication; opioids are not recommended
• A single PT session with education and home exercises may be as effective as a six-session supervised program
• Subacromial decompression surgery is no longer recommended for shoulder pain without a full-thickness rotator cuff tear

Why it matters: Overdiagnosis and overtreatment of shoulder pain drive unnecessary costs, patient anxiety, and potential harm. Clinicians who lead with reassurance and conservative care can deliver better outcomes — and spare patients from procedures they don't need.