Shoulder injuries
A model where MCDM analysis could be applied to illustrate the benefit
is shoulder soft tissue injuries and lesions, which are prevalent and
costly.12,25-28 Treatment may consist of
physiotherapy, (including manual therapy and exercise), medication, and
for more serious conditions, surgery. Given that the healing of chronic
shoulder problems often seems slow, surgery offers patients a more
immediate solution; however, this is not always the most efficacious
option. Currently, shoulder health care, including outcome reporting, is
highly variable. 29 Perhaps most importantly, for
clinicians providing such primary health care, judging the appropriate
circumstance and timeframe for imaging and/or surgery is challenging.
When considering shoulder injury treatment pathways, the shoulder
presents some specific challenges. Shoulder pain can be persistent and
reoccurring: while prevalence reporting is variable, 20-50% of shoulder
presentations were found to be still experiencing pain twelve months
after the initial complaint.26,30,31 Furthermore, the
aetiology of shoulder injuries is complex which can sometimes lead to
contradictory clinical opinions. Considering rotator cuff tears, as one
of the most common shoulder injuries, it is known that rotator cuff
tears may develop without injury and can be
asymptomatic.32 Therefore, in a health care system
with injury based funding, as in NZ, pre-existing tendon tears
complicate the decision-making for funders. Beyond initial diagnosis and
categorising, the treatment pathway decision-making process is also
complicated by multifactorial clinical criteria, health systems, and
funding. The goal of making the best judgment for the patient is not an
easy one, and interpreting clinical information can vary among
clinicians.33
Accordingly, with the ready availability of imaging as an early
decision-making tool, imaging for shoulder conditions is
overused.3 Ideally, the role of imaging is in
identifying pathology that will change the treatment pathway and detect
red flags. Although making a decision is a tangible challenge, gathering
more information in the form of imaging does not necessarily contribute
towards better management of the typical rehabilitation patient. An
identified small soft tissue injury does not always necessitate a change
of care pathway nor surgery. It is known that a small tear caused by
injury can heal,34 and a small pathological tear with
no injury can progress to a full tear that will not
heal.35 Furthermore, the shoulder can function well
with a full tear10 and shoulder pathology can be
present in both symptomatic and asymptomatic
shoulders.36
Decision-making for musculoskeletal shoulder injuries/conditions are not
based on a single factor, and each factor in the process carries a level
of importance; understanding the weighting of each key factor is a step
towards a better understanding of the decision-making process.
Potentially, shoulder injury decision-making is an area where MCDM
analysis could be used to support both the novice and expert
practitioner alike.