Shoulder Pain

Clinical Presentation

Click for Click for info

referral info for patients Exclude referred pain
Click for
for MSK from the neck, diaphragm,
more History and Examination
triage info heart, lungs, & polymyalgia
rheumatica

Click for Radiology

more (rarely indicated)
info

Assess for RED FLAGS

Past medical history of

Red Flags present No Red Flags dislocation/
subluxation of joint?

Severe trauma/ seizures

Cancer/ systemic disease Features of inflammatory
followed by pain and loss of Suspected neuro lesion – YES NO
suspected - exit pathway and arthropathy – refer urgently
movement – refer to A&E/ refer to neurology
manage/refer as appropriate to rheumatology
fracture clinic

NSAIDs/analgesics as Primary Care / Initial self-

management
required
· Analgesics/NSAIDs Click for
· Exercise sheet (see more
info
‘Information for patients)
Refer to physiotherapy
Refer all patients with new
shoulder pain and a previous
history of dislocation/subluxation No improvement after
of joint 6 weeks

Consider GP administered
Response to therapy? steroid injection
If not available in practice,
consider referring to MSK Triage
service (ESP)

Refer to MSK Triage if no

improvement or for steroid
YES NO injection Click for
more
info

Physio to refer to MSK

Discharge
Triage
Back to History and Examination
pathway

Assessment of a Painful Shoulder

Exclude referred pain from the neck, diaphragm, heart (e.g. ischaemic heart disease), lungs, and polymyalgia rheumatica (typically occurring in an
elderly woman, presenting with bilateral shoulder pain associated with stiffness and loss of function and general ill health).

Enquire about:
• It is traumatic or non-traumatic?
· Characteristics of the pain, for example onset, site of maximal pain, relationship of the pain to movement or rest (and whether it is present at
night), and additional symptoms (e.g. instability, neurological symptoms).
• Functional impairment, such as whether the dominant or non-dominant arm is affected, effects on work or sport, and instability (e.g. history of
dislocation).
• Systemic features (e.g. fever, night sweats, weight loss, generalized joint pains, rash).
• History of musculoskeletal or shoulder problems, or symptoms elsewhere.
• Significant co-morbidity (e.g. diabetes, stroke, cancer).
• Concomitant medications and potential adverse drug reactions.

Perform an examination (comparing both shoulders).

• During examination, look for painful arc (pain between 70-120 degrees of active abduction). If this is present, specific tests such as the Hawkin’s
test can help diagnose impingement.
Back to Radiology
Radiology
pathway

·· Plain
Plain XX ray
ray only
only to
to confirm
confirm suspected
suspected shoulder
shoulder dislocation
dislocation or
or shoulder
shoulder arthritis
arthritis
·· Ultrasound
Ultrasound andand MRI
MRI should
should only
only be
be ordered
ordered by
by MSK
MSK triage
triage and
and are
are rarely
rarely indicated
indicated
Back to RED
RED FLAGS?
FLAGS?
pathway

•• Cancer/
Cancer/ systemic
systemic disease
disease -- weight
weight loss,
loss, fever,
fever, constant
constant pain
pain day
day and
and night
night (not
(not associated
associated with
with movement),
movement), systemically
systemically unwell
unwell (consider
(consider also
also
history
history of
of cancer/immunosuppression),
cancer/immunosuppression), mass/ mass/ swelling
swelling suggestive
suggestive malignancy
malignancy –– exit
exit pathway
pathway and and manage/
manage/ refer
refer as
as appropriate
appropriate
•• Severe
Severe trauma/
trauma/ seizures
seizures followed
followed by
by pain
pain and
and loss
loss of
of movement
movement (e.g.
(e.g. dislocation/
dislocation/ acute
acute cuff
cuff tear)
tear) –– refer
refer to
to A&E/
A&E/ fracture
fracture clinic
clinic
•• ?Neuro lesion- unexplained wasting, significant sensory or motor deficit – refer
?Neuro lesion- unexplained wasting, significant sensory or motor deficit – refer to neurologyto neurology
•• Features
Features ofof inflammatory
inflammatory arthropathy
arthropathy –– other
other involved
involved joints/evidence
joints/evidence of of morning
morning stiffness
stiffness >> 22 hours
hours –– refer
refer urgently
urgently to
to rheumatology
rheumatology
Back to Primary Care / Initial self-management
pathway

Arthritis Research UK exercise leaflet: https://www.csp.org.uk/system/files/5_shoulder_pain.pdf

Back to Refer
Refer to
to MSK
MSK Triage
Triage ifif no
no improvement
improvement or
or for
for steroid
steroid injection
injection
pathway

·· Assessment
Assessment byby ESP
ESP
·· Self-management
Self-management // life
life style
style advice
advice
·· Investigations as required
Investigations as required
·· MDT
MDT discussions
discussions with
with specialists
specialists
·· Signposting
Signposting to
to other
other MSK
MSK provision
provision e.g.
e.g. pain
pain /physio
/physio
·· Onward
Onward referral
referral to
to secondary
secondary care
care ifif required
required
Back to Referral
Referral information
information for
for HCT
HCT MSK
MSK Triage
Triage Service
Service
pathway

The
The administration
administration team
team are
are based
based at
at the
the New
New QE2
QE2 hospital.
hospital.
Appointments
Appointments andand General
General Enquires:
Enquires: 01707
01707 247411
247411 or
or 01707
01707 247412
247412 or
or 07884
07884 547579
547579
E-
E- referral
referral enquiries
enquiries via
via the
the MSK
MSK e-referral
e-referral administration
administration on:
on: 01707
01707 247416
247416 or
or 07884
07884 547579
547579

Referral
Referral to
to the
the service
service isis via
via the
the NHS
NHS e-referral
e-referral system
system (previously
(previously Choose
Choose and
and Book).
Book). Electronic
Electronic screening
screening of
of referrals
referrals takes
takes place
place on
on aa daily
daily basis
basis by
by
clinicians.
clinicians. The
The referrals
referrals are
are either
either referred
referred directly
directly to
to secondary
secondary care
care where
where they
they manage
manage the
the Choose
Choose and
and Book
Book process,
process, or
or seen
seen for
for clinical
clinical assessment
assessment by
by the
the
team to decide the appropriate pathway
team to decide the appropriate pathway of care. of care.

Clinics
Clinics for
for assessment
assessment are
are held
held at
at The
The New
New QE2,
QE2, Hertford
Hertford County
County Hospital,
Hospital, Cheshunt
Cheshunt Community
Community Hospital
Hospital and
and Lister
Lister Hospital.
Hospital.

The
The MSK
MSK Triage
Triage Service
Service and
and the
the MSK
MSK Physiotherapy
Physiotherapy Service
Service are
are both
both part
part of
of the
the whole
whole integrated
integrated HCT
HCT MSK
MSK Service,
Service, and
and as
as such
such can
can refer
refer directly
directly to
to each
each
other
other as
as appropriate.
appropriate.

The
The MSK
MSK Physiotherapy
Physiotherapy Service
Service isis aa team
team ofof therapists
therapists specialised
specialised in
in the
the treatment
treatment and
and management
management of
of MSK
MSK Conditions
Conditions and
and based
based over
over 66 sites
sites in
in East
East and
and
North Herts. (Referral for this team is via generic email – mskphysio.enherts@nhs.net).
North Herts. (Referral for this team is via generic email – mskphysio.enherts@nhs.net).

The
The MSK
MSK Triage
Triage Service
Service isis aa team
team of
of ESP
ESP (Physiotherapists
(Physiotherapists byby background)
background) but but with
with training
training and
and advanced
advanced skills
skills for
for specialist
specialist assessment,
assessment, referring
referring for
for
diagnostics
diagnostics and
and providing
providing injection
injection therapy.
therapy. This
This team
team meets
meets regularly
regularly for
for 33 MDT
MDT meetings
meetings with
with the
the appropriate
appropriate Consultant
Consultant Surgeons
Surgeons for
for the
the upper
upper limb,
limb,
lower
lower limb
limb and
and spine.
spine. Complex
Complex cases cases are
are discussed
discussed atat these
these meetings
meetings toto provide
provide integrated
integrated care
care as
as necessary.
necessary.
Back to Information for patients and carers
pathway
Referral
Referral to
to triage
triage service
service -- http://www.enhertsccg.nhs.uk/pathway-leaflets?field_pathway_keywords_tid=msk&field_specialty_tid=All&=Apply
http://www.enhertsccg.nhs.uk/pathway-leaflets?field_pathway_keywords_tid=msk&field_specialty_tid=All&=Apply

Arthritis Research UK shoulder pain leaflet - http://www.arthritisresearchuk.org/shop/products/publications/patient-information/conditions/

shoulder-pain.aspx

Arthritis
Arthritis Research
Research UK
UK shoulder
shoulder pain
pain exercises
exercises and
and leaflet:
leaflet: http://www.arthritisresearchuk.org/arthritisinformation/conditions/shoulder-pain/shoulder-
http://www.arthritisresearchuk.org/arthritisinformation/conditions/shoulder-pain/shoulder-
pain-exercises.aspx
pain-exercises.aspx
British Pain Society leaflet, Managing your pain effectively using over-the-counter medicines: http://www.selfcareforum.org/fact-sheets/