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Shoulder Problems

Checked: 23-11-2020 by Vicky Ryan Next Review: 23-11-2022

Overview

Findings on scans on the asymptomatic population.

(Copyright: Lee Higginbotham)

Most shoulder pain is self-limiting and will improve within a few weeks, and a specific diagnosis is often not needed.

Imaging is not helpful in the majority of cases, and should only be considered in the presence of red flags, or if it is likely to change management: see the excellent flow diagram Diagnosis of shoulder problems in primary care. It is common to find ‘abnormalities’ on x-ray, ultrasound and MRI scans in the asymptomatic population.

Shoulder assessment

See the flow chart: Diagnosis of shoulder problems in primary care - for advice on assessment and management of shoulder problems (produced by BESS: British Elbow and Shoulder Society, reproduced with the permission of Oxford University). A more specific diagnosis can often be helpful to inform prognosis, such as identifying frozen shoulder which may take many months to settle.

Also remember to consider the inflammatory arthritides, such as polymyalgia rheumatica and rheumatoid arthritis, or referred pain (cervical or chest/lung/diaphragm).

For more detailed advice on diagnosis see the BMJ article: 'Assessment of shoulder pain for non-specialists' including a short video (11 minutes) on shoulder examination. The video is available to non-members but a log in is required to view the full article.

Shoulder - self-care and primary care management

Most shoulder pain is self-limiting and will improve within a few weeks. Analgesia and exercises can help.

Versus Arthritis has patient friendly information on shoulder pain, and a downloadable leaflet for exercises for shoulder pain.

Sirona also has some patient leaflets on shoulders: https://www.sirona-cic.org.uk/advice-information/leaflet-library/musculoskeletal-msk-services/shoulder-pain-resources/

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Joint injections

These should be tried in primary care initially, by appropriately trained GPs or first contact practitioners. MATS can also offer joint injections, and ultrasound guided shoulder injections may be considered with treatment failure but would need an ultrasound diagnosis first. If unsure, refer to MATS initially. There is also advice on Joint Injections for clinicians including shoulder injections on the patient.info website.

Red Flags

1. Trauma, pain and weakness - emergency department if concern about possible fracture or dislocation. If concern about an acute rotator cuff tear, refer urgently - see Acute Shoulder Clinic

2. Mass or swelling - consider tumour. Urgent imaging and refer - see suspected bone and soft tissue cancer - 2WW

3. Red skin, fever or systemically unwell - consider infection. Admit via on call orthopaedics.

Referral

Please see the Remedy page on Physiotherapy for referral options.

For suspected acute rotator cuff tear refer to Acute Shoulder Clinic via eRS (this service is not via MSK services (MATS, CATS, MIS). X-ray is required prior to referral.

For subacromial pain not responding to conservative treatment then check the criteria in the Shoulder Impingement Surgery for Subacrominal Pain Criteria Based Access Policy prior to referral to local MSK services.

There is also a Shoulder Replacement Criteria Based Access Policy.

For other shoulder problems where there are no red flags and who are not responding to conservative treatment then consider referral via local MSK services.

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.