Painful Shoulder

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Scope

Adults in primary care with shoulder pain.

Key message

Community based treatments including analgesia, landmark guided injection and physiotherapy are the mainstay of treatment for most shoulder conditions.

Patients with traumatic shoulder injuries associated with loss of function should be seen urgently either in ED or via rapid access clinics depending on local arrangements.

Guidelines are not intended to supplant clinical experience.

Out of scope

Patients with pain arising from the neck or another site in the upper limb.

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Please look at the excellent BESS (British Elbow and Shoulder Society) guidelines, available for:
- Frozen Shoulder
- subacromial impingement and
- instability

History

Is there a history of recent trauma leading to the shoulder symptoms?
Some conditions are more prevalent in certain age groups. How old is the patient?
Take a standard pain history – site, severity, duration, exacerbating and relieving factors etc.
- Shoulder pain is usually lateral to the acromioclavicular joint
- Pain arising predominantly medial to the acromioclavicular joint is usually related to the neck rather than the shoulder.

Examination

Look for deformity, swelling, scars etc
Feel: Assess bony or joint related tenderness, especially over the Acromioclavicular joint.
Move: Assess range of movement in the following planes:
- Abduction (away from the body sideways and up over the head)
- Internal rotation (how far up behind the back can the patient reach their hand. Describe this by which vertebra they can reach with their thumb)
- External Rotation (upper arm hanging vertically down, elbow at the side and flexed to 90 degrees, how far out they can rotate their hand)
Assess pain on resisted movement
Consider the cross-arm test which can help to identify Acromioclavicular Joint disease.

Clinical Features	Disposition
Combination of Trauma, Pain and Weakness should raise suspicion of Acute Cuff Tear	• Send to ED, or arrange same day X-ray. •If X-ray normal and can't achieve elevation above 90 degrees within 2 weeks, needs urgent assessment within 2-4 weeks with ESP or Ortho. •If X-ray shows fracture, send to ED or MIU.
Mass or swelling should raise suspicion of tumour	2WW
Erythema, Fever should raise suspicion of infection	Same Day Ortho Assessment
Trauma or seizure or electrocution in association with loss of function and change in shape should raise suspicion of dislocation	Send to ED
Unexplained wasting, significant sensory or motor deficit	Urgent referral
Acute onset of pain and severe tenderness over the cuff	Consider calcific tendinitis and seek early intervention by radiology

Arthritis
- Glenohumeral - Usually in older patient (aged over 60), global restriction of movement
- Acromioclavicular – cross arm test. Also high arc pain. Any patient over 30

Adhesive Capsulitis (Frozen Shoulder)
- Global restriction of movement but especially external rotation

Impingement Syndrome and rotator cuff disorders
- Classically associated with a 'painful arc'
- Typically has pain on resisted abduction

Calcific Tendinitis

Neck pain presenting as shoulder pain
- Consider treatment as per spinal pathway

Shoulder Instability
- History either of complete or partial dislocation
- Essential to differentiate between traumatic and atraumatic

Consider X-ray to differentiate Frozen Shoulder from Glenohumeral Arthritis

Consider X-ray to confirm clinical suspicion of ACJ disease. Note: many X-ray findings of degenerative joint disease are incidental. Make sure you correlate with clinical findings

Ultrasound is not usually indicated as a primary care investigation

Ultrasound guided injection is anatomically more accurate than landmark-guided injection. However, robustly blinded trials do not show significant improvements in pain relief compared to landmark-guided injection.

Community based injection will in most cases be possible in the GP practice , but at present is not a pre-referral criteria. Community physiotherapy services may have practitioners experienced in injection. If neither the GP or community physiotherapy services are able to provide an injection, we encourage referral to specialist services for this purpose

Where 'Specialist Referral' is indicated, the exact route of referral will vary depending on locality and may include the use of Intermediate Care services, Radiology services or Extended Scope Physiotherapy

Please see Red Flags for exceptions. Otherwise, numbered advice is intended to be followed in order.

Acromioclavicular Joint Disease
1. Rest, Analgesics, NSAIDS
2. Landmark guided ACJ injection in the GP surgery
3. Physio
4. Specialist referral

Frozen Shoulder
1. Rest, NSAIDS
2. Landmark guided glenohumeral injection in the GP surgery
3. Physio
4. Specialist referral

Glenohumeral Arthritis
1. If XR demonstrates OA of the glenohumeral joint, patients should receive physiotherapy and analgesia
2. Patients with persistent symptoms should be referred for a specialist opinion
3. Patients not willing or suitable to undergo surgery and who have persistent pain may gain temporary benefit from glenohumeral injection in the GP surgery

Rotator Cuff Disease
1. Rest, Analgesics, NSAIDS
2. Landmark guided subacromial injection in the GP surgery
3. Physio
4. Specialist Referral

Calcific Tendinitis
1. Rest, Analgesia, NSAIDS
2. If severe pain, consider urgent referral

Instability without history of trauma
1. Physiotherapy
2. Specialist referral

Instability with a history of trauma
1. Urgent referral

See numbered management plans above

Referral Instructions

Referral Service Selection

Specialty: Orthopaedics
Clinic Type: Shoulder and Elbow
Service: DRSS-Eastern-Orthopaedics-Shoulder & Elbow- Devon ICB- 15N

Please be guided by the Shoulder Pathway

Pathway Group

This guideline has been signed off on behalf of NHS Devon.

Publication date: December 2017

Referral