Shoulder pain – to refer or not to refer?

The prevalence of shoulder complaints in the UK is estimated to be around 14% and a new onset of shoulder pain is a common reason for people to consult their general practitioner.

For most people, shoulder pain is self-limiting or follows a fluctuating course over time. Shoulder pain can usually be managed in primary care, but persistent or progressive symptoms may require referral to secondary care.

Sub acromial shoulder pain, which is caused primarily by rotator cuff pathology, is the most common presentation. Frozen shoulder and glenohumeral osteoarthritis are less common. Most shoulder conditions are more common after 45 years of age and women are often more affected than men.

Urgent referral

Suspected septic arthritis or an unreduced dislocation both require a same day emergency referral. Any suspicion of a tumour or malignancy will need urgent referral following the local 2-week cancer referral pathway. A suspected cuff tear as a result of an acute traumatic event, needs an urgent referral and ideally should be seen in the next available outpatient clinic.

Primary Care Management or Routine Referral

Sub acromial pain should be suspected when there is no instability, symptoms are not local to the acromioclavicular joint, and where external rotation is reasonably well maintained. A painful arc into abduction, and pain on resisted abduction with the thumb pointing down (empty can test) are useful in confirming the diagnosis. Most people with improve with physiotherapy, appropriate medication, and a steroid injection where required. Secondary care referral is generally only indicated if these measures are not helpful.

Instability of the shoulder is common in 10-35-year olds. If the patient feels that the shoulder comes out of joint to any degree, then, in the absence of trauma, physiotherapy would be the first line approach. Traumatic onset or persistent problems usually require specialist review.

Acromioclavicular joint problems are more common over 35 years of age. They typically present with localised symptoms over the joint which is tender on palpation and provoked by end range abduction and the cross arm (scarf) test. Rest and anti-inflammatory medication are usually helpful, but a local steroid injection is sometimes indicated. An x-ray and orthopaedic review may be indicated in persistent cases.

Glenohumeral joint problems such as a frozen shoulder (35-65 years) and arthritis (65+ years) often present with global restriction in movement, particularly reduced passive external rotation. A loss of more than 50% (compared with the symptom free side) is typical. An x-ray to further differentiate a frozen or arthritis shoulder is useful, although the management of both is similar in the first instance. Appropriate pain medication, physiotherapy, and an intra-articular steroid injection are most useful, followed by specialist review if symptoms progress.

Sudden onset of bilateral shoulder pain in an older person should raise a suspicion of polymyalgia rheumatica (PMR), and inflammatory markers should be checked. PMR can often be managed in primary care, but consider referral to rheumatology if there is uncertainty about the diagnosis.

You can find further information here on the diagnosis of shoulder problems in primary care. You may also find these exercises useful for your patients.