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Shoulder Pain - Coggle Diagram
Shoulder Pain
History
Instability or past history of dislocation
Functional impairment - dominant or non-dominant arm.
Stiffness
Trauma
Neck pain or other upper limb pain
Day-to-day activities affected or sport/work
Characteristics of pain: onset, duration, site of maximal pain, pain at rest, on movement or both, night pain, does pain affecting sleeping position
Pain in other joints
Systemic features such as fever, night sweats, weight loss, rash, respiratory symptoms
Occupational and sporting activities
Neurological symptoms
Current medications
Past history of shoulder or MSK problems
Family history
Examination
Assess active, passive and restricted movement.
Assess flexion, extension, abduction, adduction and internal/external rotation.
Palpate the should bones (clavicle, proximal humerus, scapula) and joints (sternoclavicular, acromioclavicular, glenohumeral), looking for tenderness, warmth, swelling and crepitus
Look for painful arc of abduction - if present check if pain on abduction with the thumb down or worse against resistance
Inspect the should from the front, side and behind for muscle wasting, swelling, deformity or bruising
erform the cross-arm test. This is positive if there is pain over the acromioclavicular joint when the person raises the affected arm to 90 degrees, then actively adducts it.
Neurological exam if indicated
Examine the neck, arms, axillae and chest wall for possible sources of referred pain. Assess the range of movement of the cervical spine.
If neck movement reproduces the pain, and the shoulder pain is thought to be referred from the neck, see the CKS guidelines
Management: Glenohumeral joint osteoarthritis
Assistive devices for specific problems with activities of daily living. Occupational therapist.
Analgesia Mild-to-moderate pain
Weight loss if appropriate
Consider corticosteroid injection for short-term management in acute exacerbation
Strengthening activities. Physiotherapy
Refer to secondary care if: conservative measure do not control pain, stiffness having a significant impact, diagnosis is uncertain.
Education and advice
Base decisions on severity of symptoms, impact on function, quality of life, mood, occupation and leisure activities.
Management Rotator Cuff Disorder
Modification of activities that exacerbate symptoms
Analgesia - Mild-to-moderate pain
Advise rest in the acute phase with gradual activity increase
Physiotherapy
Adopt shared decision making
Subacromial corticosteroid injection
Consider referral to intermediate/secondary care if appropriate
Initial management
Urgent referral if presentation with any red flags
Also consider urgent investigations/referral: systemic symptoms, undiagnosed severe shoulder pain, severe restriction of movement, history of trauma and being seen acutely.
Urgent same day assessment: Suspected joint infection, unreduced dislocation, acute trauma
Urgent referral: malignancy, acute rotator cuff tear caused by trauma, inflammatory arthritis, neurological lesion.
For suspected intrinsic shoulder disorders, follow the Oxford University hospitals guidelines for the diagnosis, treatment and referral of common shoulder problems in primary care
http://www.ouh.nhs.uk
Initial management with no red flags:
Shared decision making
Consider physiotherapy referral
Consider review in 2 weeks if severe with safety netting
Explain self limiting and rehabilitation can be at least 6 months
Consider short period of time off work eg one week if direct link between this and pain
Advise to carry out normal activities as much as able
Consider work and activities
Provide appropriate analgesia eg paracetamol first line, 2nd line NSAID or codeine.
Explain diagnosis and offer information
Red flags
Trauma, pain and weakness or sudden loss of ability to activiely 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 should dislocation
New symptoms of inflammation in several joints - suspect inflammatory arthritis
Primary Care Frozen Shoulder Management
Consider - analgesia, physiotherapy input, intra-articular corticosteroid injection, referral to secondary care
Consider stepped approach from least to most invasive.
Activity modification and pain control - continue to use arm/ease spasm, avoid movements which worsen pain, take analgesia, hot packs, support arm in bed with pillow.
Explain diagnosis: Pain main problem gradually improves while stiffness worsens and becomes main problem then resolves. Self-limiting but can take months/years to resolve.
Analgesia for Mild-to-moderate pain. 1st line Paracetamol. 2nd line NSAID or codeine. Regular dosing more effective than as required. NSAID consider gastric protection.
Management Instability Disorders
Refer immediately to an Emergency department if acute dislocation is suspected
Following reduction of traumatic shoulder dislocation: encourage early mobilisation, refer to physiotherapy, likely follow up at fracture clinic.
Refer urgently to Orthopaedics if rotator cuff tear is suspected
Refer to shoulder surgeon: first time dislocation, recurrent painful dislocation, symptoms impacting on person's job or leisure activities, should dislocation associated with epileptic seizure, symptoms not improving with physiotherapy or associated injuries.
Refer to physiotherapy: atraumatic should instability suspected, muscle patterning instability.
Investigations guided by suspected cause
Bloods if malignancy, polymyalgia rheumatica or inflammatory arthritis is suspected. Consider testing for diabetes if this is suspected in a person with shoulder pain (frozen shoulder is more common in people with diabetes than those without diabetes).
Consider anteroposterior and lateral shoulder x-rays: history of trauma, not improving with conservation treatment, symptoms longer than four weeks, movement significantly restricted, sever pain, red flags present, arthritis is suspected.
Ultrasound/MRI should not usually be requested by primary care
Causes
Shoulder
Acromioclavicular joint disorders
Glenohumeral joint osteoarthritis
Instability disorders
Inflammatory arthritis
Frozen shoulder
Paget's disease
Rotator cuff disorders
Avascular necrosis of the humeral head
Septic arthritis
Referred pain
Polymyalgia rheumatica
Malignancy
Referred pain from the neck, diaphragm, heart, or lungs
Early herpes zoster
Management: Acromioclavicular joint disorders
Osteoarthritis of AC joint
Consider corticosteroid injection if pain is severe
Arrange x-ray and refer to orthopaedics if no/temporary improvement following above measure
Consider physiotherapy
See Oestoarthritis summary for more information
Analgesia - Mild-to-moderate pain
Activity modification
Acromioclavicular joint injuries
Initially, advise rest, consider providing a sling for 5–7 days, and offer analgesia
Start gentle mobilisation and strengthening when the person is more comfortable. Consider referral to physiotherapy
Advise the person to resume normal activities as tolerated, but avoid heavy lifting and contact sports for 8–12 weeks
Pain caused my mild sprain following acute injury:
Refer for x-ray or A&E dependent on clinical judgement
Refer to orthopaedics if symptoms are not settling following conservative management. Consider earlier referral for certain groups for whom shoulder pain is particularly disabling.