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Shoulder - Subacromial Pain
The prevalence of shoulder complaints in the UK is estimated to be 14%, with 1-2% of adults over 45 consulting their general practitioner annually with a new problem.
Subacromial shoulder pain from rotator cuff pathology, including tendonitis, calcific tendonitis and rotator cuff tears reportedly accounts for up to 70% of all shoulder pain problems. (BESS/BOA guidelines).
Painful shoulders pose a substantial socioeconomic burden. Disability of the shoulder can impair ability to work or perform household tasks and can result in time off work.
It is estimated that the overall prevalence of rotator cuff tears is 34% and that risk increases significantly with age. Partial tears are more prevalent than full thickness tears.
Key Messages
Community based treatments including analgesia, landmark guided injection and physiotherapy are the mainstay of treatment for most shoulder conditions
Scope
Adults with rotator cuff pathology
- Diagnosis is based on history and examination (see algorithm)
- Impingement Syndrome and rotator cuff disorders are classically associated with a 'painful arc' and pain on resisted abduction
Differential Diagnoses
- Adhesive Capsulitis (Frozen Shoulder)
- Calcific Tendinitis
- Neck pathology presenting as shoulder pain
- Shoulder Instability
- Combination of Trauma, Pain and Weakness should raise suspicion of Acute Cuff Tear
- Mass or swelling should raise suspicion of tumour
- Erythema, Fever should raise suspicion of infection
- Unexplained wasting, significant sensory or motor deficit
- Acute onset of pain and severe tenderness over the cuff
The following strategies/interventions are suitable for employment in primary care (by either GP or physiotherapist):
- Simple advice (rest/activity modification/heat packs)
- Analgesia/NSAIDs
- Landmark steroid injection into the subacromial space
- Physiotherapy exercise programme: Therapy for at least 3 months of physiotherapy is the minimum requirement.
Note that ultrasound should NOT be employed in primary care. This is currently used in primary care as a screening tool to look for structural pathology, and has no value in predicting the likelihood of the patient being offered surgery.. The hospital shoulder team would prefer to undertake ultrasound to confirm a clinical diagnosis and act accordingly as part of the shared decision making process when considering surgery.
Many patients with rotator cuff tear do NOT require surgery, but a positive ultrasound undertaken in primary care tends to lead to an expectation of surgical relief.
In a patient with persistent pain who has not responded to activity modification, analgesia, physiotherapy for more than 3 months and a single steroid injection, a referral can considered to specialist service.
Referral Instructions
Refer to Orthopaedics e-Referrals Service Selection
- Speciality: Orthopaedics
- Clinic type: Shoulder
- Service: DRSS-South Devon & Torbay-Orthopaedics-Shoulder & Elbow- Devon CCG - 15N
Referral Forms
Pathway Group
This guideline has been signed off on behalf of NHS Devon.
Publication date: December 2017
