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Shoulder Pain

  

Shoulder pain is a common problem with a number of different causes. It's often a symptom of another problem.


GP and Self-management

Frozen shoulder

  • NSAID, moderate analgesia
  • Intra-articular steroid injection, 1-2 (by GP or physio)
  • Smoking cessation/ advice
  • Refer early if significant pain and restricted movement

OA of acromio-clavicular joint

  • NSAID, moderate analgesia.
  • Steroid injection x 1-2 (or refer)
  • If no improvement with x 2 injections and moderate/ severe changes a/c joint x-ray, refer to secondary care.

Rotator Cuff Tears & Shoulder Impingement

  • Subacromial steroid injection x 1-2 (by GP or physiotherapist). Start physio AFTER the injection. If initial injection failed to provide any improvement consider referral for guided injection. If initial injection provided improvement in symptoms, re-injection unguided.

Sprains/minor injuries

  • NSAIDS/ mod analgesia
  • Advise patient on deformity
  • Routine physiotherapy
Investigations

Please DO NOT use ultrasound as a screening tool for shoulder pain as 30% of general population over 60 years will have some form of cuff tear and nearly all will have tendinopathy!

Chronic/ Recurrent Dislocation

  • It is now no longer advised to refer for MRI to further investigate glenoid labrum (and requests will be rejected by UHCW Radiology

Consider referral to physiotherapy initially or orthopaedic shoulder clinic (where MRI Arthrogram may be preferred and requested within secondary care)

Frozen Shoulder

  • X-ray in pts over 50 to exclude OA of glenohumeral joint (A-P & axial)

Osteoarthritis of Shoulder

  • X-ray of shoulder – A-P & axial
  • Diagnostic Ultrasound if rotator cuff involvement is suspected.

Rotator Cuff Tears & Shoulder Impingement

  • Diagnostic ultrasound if rotator cuff involvement is suspected
  • If Pt < 60 yrs old with moderate to large full thickness tear (>1 cm), refer directly to orthopaedics.
  • If Pt > 65 yrs old with moderate to large full thickness tear, adopt all conservative measures prior to orthopaedic referral.

Shoulder – acromio-clavicular joint

  • X-ray – plain A-P
  • Ultra-sound if rotator cuff involvement is suspected

Shoulder Decompression for Subacromial Pain

Arthroscopic subacromial decompression for pure subacromial shoulder impingement should ONLY be offered in appropriate cases.

‘Pure subacromial shoulder impingement’ means subacromial pain NOT caused by associated diagnoses such as rotator cuff tears, acromio-clavicular joint pain, or calcific tendinopathy.

Non-operative treatment such as physiotherapy and exercise programmes are effective and safe in many cases.

For  persistent or progressive symptoms, in spite of adequate non-operative treatment, surgery will be funded.

The latest evidence for the potential benefits and risks of subacromial shoulder decompression surgery should be discussed with the patient and a shared decision reached between surgeon and patient as to whether to proceed with surgical intervention.

Refer to Adult Physiotherapy Service – Coventry

Please refer to Adult Physiotherapy for the following pathologies, if patients are not improved with relative rest or analgesic advice:

  • Sub Acromial Impingement
  • Articular or bursal partial thickness tear (PTT) of the Rotator Cuff
  • Full thickness tears (FTT) of the rotator cuff in pts > 60 years old
  • Frozen Shoulder/ Adhesive Capsulitis
  • OA/ sprain AC Joint
  • Early OA glenohumeral Joint

Here they will be assessed and treated with the following:

  • Self-management and education
  • Exercise therapy
  • Manual therapy
  • Acupuncture
  • Soft tissue mobilisations
  • Guided or Blind Intra/ extra articular injection

Do not refer to Physiotherapy for the following issues. Instead refer directly to secondary care:

  • Patients currently under the care of a consultant for the same condition
  • Patient is amenable to surgical intervention where applicable
  • Known cancer or suspicion of tumour (Two Week Wait)
  • Acute traumatic dislocation – send to A&E
  • Recurrent (>2 episodes) shoulder dislocation
  • Bankhart / SLAP lesion (type III & IV) – viewed on MRI/ MRA
  • Suspicion of fracture
  • Bone disease or infection
  • Full thickness Rotator Cuff Tear < 60 yrs old
  • Moderate to severe OA of the glenohumeral joint  on x-ray
Referral to secondary care

Refer directly to secondary care if any of the following are present:

  • Patients currently under the care of a consultant for the same condition
  • Patient is amenable to surgical intervention where applicable
  • Known cancer or suspicion of tumour (Two Week Wait)
  • Acute traumatic dislocation (to A&E)
  • Recurrent shoulder dislocation with a traumatic history
  • Multiple dislocations with positive findings on imaging (SLAP lesion Grd 2+)
  • Suspicion of Bankhart / SLAP lesion
  • Suspicion of fracture
  • Bone disease or infection
  • Severe global loss of movement <90 degree flexion or abduction or <20 degrees external rotation
  • Full thickness Rotator Cuff Tear < 60 yrs old
  • Symptoms over three months.
  • Bone-on-bone confirmed on X-ray
  • Moderate to severe changes on x-ray such as reduced joint space, sclerotic changes, superior migration of the humeral head, cystic bone formation and osteophytic formation
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