Shoulder Pain Protocols

Introduction : Diagnostic Triage and Management Guidelines

1. Patient Group

Adults aged 18 years and over with routine shoulder problems

Patients who have had recent surgery should be referred directly to
Secondary Care

2. Diagnostic Triage and Management Guidelines

Perform diagnostic triage to exclude serious pathology.

See Section 1 for Triage and Management guidelines

3. Abbreviations

ABD Abduction
ACJ Acromio clavicular joint
IA Intra articular
LR Lateral rotation
MR Medial rotation
MUA Manipulation under anaesthetic
S.A.D. Sub acromial decompression
W.A.D. Whiplash associated disorder
 Diagnostic Triage Management Guidelines

Red Flags
Possibility of tumour Consider prompt referral to Secondary Care
Possibility of Infection
Undertake appropriate investigations e.g.
Clinical Features: FBC, ESR, MRI, etc.

< 20 years or > 60 years of age

Constant unremitting pain
Systemic signs and symptoms
Hot, red and swollen shoulder (onset non-
traumatic)

Shoulder Capsulistis

Clinical Features: Investigations:

Capsular restriction present – more loss of X ray not routinely required unless sinister
pathology suspected
LR than ABD than MR
Common between ages of 40-65 years
Onset either insidious or post traumatic First Line Management
Pain within C5 Dermatome
Maybe constant in nature with sleep First Stage:
disturbance
Maybe history of Diabetes • Advise and explanation
• Physiotherapy
3 Stages: • NSAIDS/Analgesia
• Cortisone Injections x 3 – if available
1. 3-6 months, pain main symptom in primary care – consider referral to
2. 6-12 months, Pain reduces and joint MSK Tier 2 service
stiffness increases Second Stage:
3. 1 year + joint stiffness resolves
• Physiotherapy
85% make a full recovery within 2 years
Second Line Management:

If symptoms fail to settle and high

functional disability persists, refer to
Orthopaedics as may benefit from MUA
 Diagnostic Triage Management Guidelines

Subacromial Bursa

Clinical Features: Investigations:

• Painful arc None required if typical presentation. Consider

• Full passive range movement
• Painful resisted abduction/lateral
rotation
• Distraction / impingement tests
positive
• Pain increased with activity and side
lying
X ray if diagnosis unclear or fails to respond to
treatment – maybe calcified bursa
20º inclined X ray to check for shoulder spur
First Line Management
• Steroid injection x 2 – usually respond
well, if available in primary care –
consider referral to MSK Tier 2 service -
Physiotherapy post injection

Second Line Management

Acromio Clavicular Joint
Clinical Features:
• Insidious or traumatic onset – may occur
following W.A.D.
• Local pain within C4 dermatome
• Pain at end range Gleno-humeral
movements
• Scarf test positive
• +/- painful arc
• maybe associated with ACJ subluxation
Rotator Cuff Tear
Clinical Features:
• Acute or chronic nature
• Athlete or >45 years old
• Acute: full passive ROM, no active ROM
• Sub acute/chronic: limited function,
painful arc, weakness, night pain to
varying degree
Consider referral to MSK Tier 2 service
If symptoms fail to settle, refer to Orthopaedics
- may need S.A.D.
Investigations:
X ray may reveal degenerative changes or joint
disruption
Consider X ray if failing to settle
First Line Management
• Physiotherapy
• IA Steroid Injection, if available in
primary care – consider referral to MSK
Tier 2 service
Second Line Management
Consider referral to MSK Tier 2 service
Refer to Orthopaedics if X ray shows
significant joint disruption or symptoms failing
to settle
Acute/Sub Acute
- Less than 12 months
Refer to Secondary Care
Early surgery required for best results
Chronic Tear
- More than 12 months:
SA Injection, if available in primary care –
consider referral to MSK Tier 2 service
Physiotherapy
Refer to Ortho, if symptoms persist
 Diagnostic Triage
Sterno-Clavicular Joint
Clinical Features:
• Onset may be overuse or trauma
• Pain felt over sterno-clavicular joint
• Pain increased with full elevation of
shoulder
• Pain felt on retraction and protraction of
the shoulder
• Clicking often reported
• Not a common lesion but usually
responds well to IA injection and
physiotherapy
Management Guidelines
Investigations:
None routinely required but may demonstrate
degenerative changes or joint disruption
Consider X ray if failing to settle
First Line Management
• Physiotherapy
• IA Steroid injection, if available in
primary care – consider referral to MSK
Tier 2 service
Second Line Management
Consider referral to MSK Tier 2 service
Refer to Orthopaedics if significant joint
disruption revealed on X ray or symptoms
failing to settle