Painful Shoulder

Scope

Adults in primary care with shoulder pain

Key Messages

In the absence of trauma, GPs should give analgesia and refer to Physiotherapy initially.
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.
A plain X ray should accompany every referral (see Investigations section).
A clinically guided injection can be given if first line management fails to improve symptoms.
Refer to ICATS / Secondary Care if the symptoms continue or if the diagnosis is in doubt.
Ultrasound or MRI (including U/S guided injection) is not available to Primary Care.
Clinical and Logistic advice for GPs/ESPs/ENPs/FCPs etc is readily available (within 24 hours ) from : plh-tr.shoulderandelbowteam@nhs.net

Out of Scope

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

Assessment

Please look at the excellent Diagnosis of Shoulder Problems in Primary Care Infographic for assessment and management guidance.

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
Red skin, Fever or systemically unwell 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

Investigations

**ADDENDUM November 2021 – Due to the current waits for plain X-rays in some areas, an attached X-ray report will no longer be mandated. However, all referral letters must state that an X-ray has been done or that it has been requested. Please do attach reports if possible as they improve the efficiency of referral triage) **

A plain X-ray of the shoulder report should ideally accompany all shoulder referrals in all those over 18 years of age.
An X-ray can differentiate Frozen Shoulder from Glenohumeral Arthritis or 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
MRI / Ultrasound is not indicated or available as a Primary Care investigation

Management

Please look at the excellent Diagnosis of Shoulder Problems in Primary Care Infographic for assessment and management guidance.

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

Clinical and Logistic advice for GPs/ESPs/ENPs/FCPs etc is readily available (within 24 hours ) from : plh-tr.shoulderandelbowteam@nhs.net