Shoulder pain:pain arising from the shoulder
Causes
Rotator cuff disorders.
Frozen shoulder.
Instability disorders.
Acromioclavicular joint disorders.
Glenohumeral joint osteoarthritis.
Inflammatory arthritis
Septic arthritis
Referral - urgent referral to 2o care and/or investigation
Management
Assessment
Red Flags
Trauma, pain and weakness, or sudden loss of ability to actively raise the arm (with or without trauma): suspect acute rotator cuff tear.
Any shoulder mass or swelling: suspect malignancy.
Red skin, painful joint, fever or the person is systemically unwell: suspect septic arthritis.
Trauma leading to loss of rotation and abnormal shape: possible shoulder dislocation.
New symptoms of inflammation in several joints: suspect inflammatory arthritis.
Are systemic symptoms such as fever, night sweats, weight loss or new respiratory symptoms.
Is undiagnosed severe shoulder pain or severe restriction of movement.
Is a history of trauma and the person is being seen acutely.
Same day referral
Suspected joint infection (red skin, person has fever or is systemically unwell).
Unreduced dislocation (trauma, epileptic fit or electric shock leading to abnormal shoulder shape and loss of rotation).
Acute trauma, depending on clinical judgement.
Malignancy (past history of cancer, symptoms or signs of cancer, mass or swelling, unexplained deformity, lymphadenopathy). Follow the local 2-week referral pathway.
Acute rotator cuff tear caused by trauma (trauma, pain and weakness). Refer urgently to orthopaedics. The person should be seen in the next available specialist shoulder clinic.
Inflammatory arthritis. Follow the local rheumatology referral pathway.
Neurological lesion (unexplained wasting, significant motor or sensory deficit). Discuss with neurology, neurosurgery or orthopaedics, depending on clinical judgement.
Explain diagnosis, offer information leaflet
explain self limiting and rehab can take about 6 months
consider work and leisure activities. Consider Employers OH dept referral
review in 2 weeks with strong safety netting
Analgesia- Paracetamol, if ineffective offer NSAIDS or codeine
shoulder instability
post traumatic pain
no improvement to pain/function in 3 months
Referral to MSK clinic for physio or corticosteroid injection
refer to Physio
Shared decision making
look, feel and move, joint above and below (neck, arms, chest and axilla) actively and passively
neurological exam if apt
Hx using SOCRATES
Blood tests should be performed if malignancy, polymyalgia rheumatica or inflammatory arthritis are suspected. Testing for diabetes should be considered for people with frozen shoulder.
X-rays should be considered if: there is a history of trauma; there is little improvement with conservative treatment; symptoms last more than four weeks, there is severe pain or restriction of movement, suspected arthritis or any red flags are present.