Before I look at your imaging.
The first question I ask every new shoulder patient is not about the MRI. It is about the life the shoulder is supposed to serve.
Most shoulder consultations begin in the wrong place. They begin with the scan.
The patient sits down, hands me a USB stick, and waits for me to load the images. I do load the images — eventually. But not first.
First I ask what they need their shoulder to do.
The answer changes the operation. A rotator cuff repair in a 52-year-old plasterer is not the same operation as a rotator cuff repair in a 52-year-old amateur tennis player. The MRI may look identical. The tear may be the same size, the same retraction, the same fatty infiltration on the muscle. But the plan is different — and the plan is what you came for.
Some examples of what that question actually changes.
The surfer.
The surfer needs forward elevation and overhead reach with rotation under load. She is in the water four mornings a week. She is willing to do six months of rehabilitation if it means she paddles out again at the end of it. She is not willing to lose external rotation to gain stability she does not need.
The shoulder you need back is the one that paddles. I plan accordingly.
The plasterer.
The plasterer needs sustained overhead work without pain at three hours. He has been working through the pain for two years. He is not asking for the strongest possible shoulder — he is asking for the shoulder that gets him to a Friday afternoon without a Voltaren at lunch.
The plan is the repair that holds up at three hours of work, not the repair that looks best on the post-op MRI. Those are not always the same operation.
The grandmother.
The grandmother needs to lift a six-month-old to her shoulder without thinking about it. She does not need overhead. She does not need rotation under load. She needs the shoulder that picks up a grandchild on a Sunday afternoon.
A reverse shoulder replacement is the right operation for her cuff-deficient arthritic shoulder. The fact that the implant restores active elevation — not external rotation under load — is not a limitation in her case. It is exactly what she came for. The plan and the life match.
The imaging matters. After.
None of this is to say the MRI does not matter. It matters enormously. It tells me the tear size, the retraction, the tendon quality, the bone stock, the soft-tissue picture. It tells me what is technically possible.
But the imaging does not tell me what is right. The patient does. And the only way to know is to ask the question first.
So if you bring me a scan, I'll look at it. After.
— Joe