KISS: Shoulder Pain

Rule out Red Flags

• Joint Infection - red skin, fever, systemically unwell = same day emergency referral.
• Unreduced traumatic shoulder dislocation = same day emergency referral.
• Malignancy - mass, swelling, unexplained deformity, night pain, previous cancer, consider referred pain from apical lung cancer = 2 week cancer referral.
• Acute rotator cuff tear (can be 'easily missed' BMJ 2017;359:j5366) = urgent referral, ideally next available outpatient clinic:
• Trauma, pain, weakness; unable to abduct arm above shoulder level, especially if not limited by pain.
• Be alert to acute tears after shoulder dislocations, and do not be reassured by patients discharged from ED with 'normal' Xray.
• Systemic/widespread symptoms e.g. PMR, inflammatory arthritis.

General principles of managing shoulder pain (NB quick video reminder on shoulder exam click here):

• Management should be personalised, and key aspects to consider are the duration of symptoms, patient expectation, hand dominance, occupation, and level of activity/sports.
• Is it shoulder pathology or is it pain from the neck or referred pain from elsewhere?
• Commonest non-shoulder cause of pain is the neck - see different pain distribution for neck/shoulder (click here) and simply move neck then shoulder to see which part reproduces the pain.
• Consider also referred pain from lung apex (?malignancy) and diaphragm (shoulder tip pain).
• Physiotherapy/exercise therapy is a key component to most shoulder problems, but warn patients that improvement will take 6-12 weeks. If physio access is limited see links below for home exercises.
• Steroid injections:
• Can be considered in some situations (see below) but should be done in addition to (not instead of) physio/exercise therapy. 
• Do NOT need to be image-guided in primary care.
• Steroid injections and COVID (Joint guidance Nov 2020 inc. BSR/BOA/RCGP):
  
• The impact of intra-articular (IA) injections on COVID is still unknown but there are concerns they could worsen outcomes.
  
• Particular consideration of IA injection risks is needed for more clinically vulnerable groups e.g. aged > 70, adults in BAME groups, those with diabetes, chronic respiratory disease, high BMI.
  
• Analgesia, rest and exercise therapy should remain fist line treatments, but IA injections can be considered if first line measures failed or have high levels of pain and disability.
• If doing IA injection use minimum appropriate dose.
• Imaging - X-ray can be considered (see below) but ultrasound or MRI should NOT be used in primary care, unless part of a specific local treatment pathway.

• If traumatic refer urgently to orthopaedics (probably fracture clinic) - younger patients at risk of labral injury and high risk of recurrence, older patients at risk of acute cuff tear.
• If atraumatic (typically young patients aged 10-35) = refer physio; warn patients can take 6 months to resolve; consider early referral to shoulder specialist if frequent ED attendance, persistent displacement, aged <18 or regular absence from school or work. 

Suspected AC joint pathology (typically aged >30):

• Pain and tenderness localised to AC joint; high arc pain; +ve cross arm ('Scarf') test.
• Management: 
• Rest, NSAIDS, analgesia, modify activity (e.g. avoid cross body shoulder adduction, avoid lifting).
• Consider physio.
• Consider ACJ steroid injection.
• Xray and consider secondary care referral if not improving despite the above measures. 

Suspected glenohumeral joint (GHJ) disorder:

• Globally restricted painful range of movement. 
• Key feature to differentiate from other shoulder disorders is reduced passive external rotation.
• Xray should be considered to help differentiate between frozen shoulder and OA, as well as to rule out other causes e.g. avascular necrosis. 

Frozen shoulder:

• Background:
• Generally presents in 35-65 year olds.
• More common in those with diabetes or cardiovascular disease. 
• 3 phases: painful phase, stiff phase, resolution phase.
• Generally settles spontaneously over 18-24 months but can be persistent for several years in some.
• Presentation:
• Gradual onset pain in the shoulder/deltoid region and stiffness.
• Progresses to a globally restricted painful ROM in all planes, disproportionately affecting passive external rotation.
• Management:
  
• Analgesics, NSAIDs (if appropriate, consider PPI cover).
• Exercise therapy for 6-12 weeks - physio if available but home exercises are also recommended (for basic home exercises from versus arthritis click here).
• IA steroid injection can be considered - ideally in the painful/early phase.
• Refer if no improvement by 3 months (sooner if severe symptoms or unable to manage treatments).

GHJ OA:

• Background:
• Generally presents in > 60 year olds.
• Primary OA is relatively rare as non-weight bearing joint.
• Look for signs of OA in other joints which may increase the likelihood of GHJ OA.
• Presents in a similar fashion to frozen shoulder hence need to consider Xray to help differentiate.
  
• Management:
• Analgesics, NSAIDs (if appropriate, consider PPI cover).
• Exercise therapy - consider physio or home exercises (click here).
• IA steroid injection can be considered for short term relief of OA flare.
• Refer if failure of conservative treatments or patient wishes to consider shoulder replacement but there are very limited other surgical options. 

• Background:
• Covers a wide range of underlying pathologies generally caused by rotator cuff tendinopathies or partial/degenerative cuff tears.
• Commonest cause of shoulder pain in primary care.
• Presentation:
• Shoulder/deltoid pain, generally worse in overhead positions and painful to lie on.
• Active movements are generally more painful than passive; preservation of passive external rotation.
• Painful arc of abduction and pain on abduction with thumb down/worse against resistance (Jobe's test/empty can test).
• Management:
• Exercise therapy and physio should be the cornerstone of treatment (click here for home exercises if physio access is limited).
• IA steroid injections can be considered to aid physio/exercise but NO MORE than 2 (evidence suggest repeated injections increase the risk of tendon damage). 
• Refer (and consider Xray) if no better by 6-12 weeks.