Q: I had X-rays and a bunch of tests done to figure out what's wrong with my shoulder. I was told I have a shoulder impingement and need an MRI. The MRI wasn't "conclusive" so now I need "diagnostic arthroscopy." All this is adding up to a big medical bill. Am I just being led down the path of no return?

A: Shoulder impingement syndrome can be difficult to diagnose. Sure the physician can tell the symptoms that characterize this problem: you have trouble lifting your arm up overhead easily. The same thing may happen when you lift your arm out to the side and up. You get the arm up part way and then it either hurts too much to keep going or it just won't go.

If you use your other hand to help lift the involved arm and get it past a certain point (usually between 90 and 120 degrees away from the body), then you can complete the full range-of-motion. This is a classic picture of what is referred to as shoulder impingement. You likely have the same problem in reverse: as you try to lower your arm, you might feel a painful catch. You have to use the hand on the painfree side to help the painful arm move back down to your side.

Studies show that there are really quite a few different problems that could be causing that type of clinical picture typically referred to as impingement. For example, rotator cuff tendinosis, partial-thickness tear of the rotator cuff, full-thickness tear, bursitis, or tight posterior capsule can all create symptoms of pain and limited motion known as impingement.

In order to make the diagnosis, the physician is directed to do exactly as yours has done...start with a few simple tests that don't cost anything extra. Take an X-ray to look for something obvious (fracture, bone spur, arthritis). If that doesn't yield the answer, then order an MRI. And finally, an arthroscopic exam is the most accurate (but more expensive) way to get inside that joint and find out what's causing the problem.

An accurate diagnosis is needed to direct treatment. In the end, this can help direct treatment. You may start with conservative (nonoperative) care with antiinflammatory medications, cortisone injection(s), and/or physiotherapy. But if you need surgery, the arthroscopic exam can be both diagnostic and treatment all rolled into one. It sounds like whatever is going on for you, it's not a cut and dried easy-to-diagnose problem. The arthroscopic exam will likely clear up the diagnosis and set you on the right treatment course.

Reference: Anastasio Papadonikolakis, MD, et al. Published Evidence Relevant to the Diagnosis of Impingement Syndrome of the Shoulder. In The Journal of Bone and Joint Surgery. October 5, 2011. Vol. 93-A. No. 19. Pp. 1827-1832.