Painful Shoulder

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.

Assessment

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.

Red Flags


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

​Differential Diagnoses

  • 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

Investigations

  • 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

Management

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

Referral

See numbered management plans above

Referral Instructions

Referral Service Selection

  • Specialty: Orthopaedics
  • Clinic Type: Shoulder and Elbow
  • Service: DRSS-Eastern-Orthopaedics-Shoulder & Elbow-NEW Devon CCG- 99P

Please be guided by the Shoulder Pathway

Referral Forms

DRSS referral form

Supporting Information

GP Information

NICE Clinical Knowledge Summary on shoulder pain

Cochrane review of landmark guided vs ultrasound guided injection

Patient Information

Arthritis Research Council on Shoulder Pain

Pathway Group

This guideline has been signed off by the Planned Care Clinical Leads on behalf of NEW Devon CCG

Publication date: December 2017

 

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