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.
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.
Report launch – State of musculoskeletal health 2018
Arthritis and related conditions, such as back pain and osteoporosis, affect 17.8 million people across the UK. They are the single biggest cause of pain and years lived with disability in the UK, resulting in 30.8 million working days lost each year.
Versus Arthritis are committed to building our understanding and awareness of the burden and impact of musculoskeletal conditions in the UK. We are delighted to announce the launch of the State of Musculoskeletal Health 2018. The compendium, updated annually, is an important resource providing the best available picture of the most prevalent musculoskeletal conditions in the UK. It is a resource for health professionals, policy makers, public health leads and anyone interested in musculoskeletal health.
The burden of musculoskeletal illness can be defined by the number of people affected by a condition and at risk of developing the disease, but also by its wider impact. Musculoskeletal conditions can have a significant impact both on a personal and societal level. An individual’s home life, relationships and work can all be affected, causing repercussions for society and the wider economy, for example through the cost of treatment or lost productivity.
The report is divided into five main sections:
- What is the scale of the problem
- Key factors affecting musculoskeletal health
- What is the impact?
- Economic benefits of musculoskeletal research
- Condition specific statistics (incl. prevalence, risk factors, comorbidities, and impact)
We believe that with the best information you can build awareness, make informed decisions, feel more confident and ultimately help more people with musculoskeletal conditions. If you have any questions about the document, please get in touch with us at firstname.lastname@example.org.
Spotlight on our Centre for Musculoskeletal Health and Work
Musculoskeletal conditions, such as back pain or arthritis, are some of the main causes of inability to work in the UK, accounting for loss of 30 million working days per year.
There is currently a lack of scientific evidence to inform policies and interventions aimed at reducing this burden. The Arthritis Research UK-MRC Centre for Musculoskeletal Health and Work, at the University of Southampton, was set up in 2014 to address this problem.
The centre is aiming to establish a national resource for advice on musculoskeletal health and work, accessible to Government, employers, workers, health professionals and patients, and actively promote best work and clinical practice.
It is hoped that through collaboration with teams across the UK, the work of this centre will enable workplace and work-related musculoskeletal conditions to be properly addressed, thus reducing the number of working days lost to these conditions and benefiting patients, workers, employers, and society at large.
Over the last 3 years, the centre has successfully built a national profile so that UK policy makers are now coming to it for support and information. The centre is working to grow its reputation internationally with collaborations across Europe and in Australia.
‘Room to manoeuvre’ – new report on aids and adaptations for people with arthritis
For people with arthritis, aids and adaptations can improve quality of life and empower people to live independently at home. However, despite policy being in place to ensure good provision of home aids and adaptations, people with arthritis are living without them.
Did you know…
- Local authorities have a legal duty to provide, or arrange for, services to prevent people developing care needs, and delay the impact of an existing disability.
- Anyone can ask for a needs assessment, and the local authority has a legal duty to conduct one to determine whether a person is eligible for care and support, including community equipment such as aids or minor adaptations.
- Our recent survey found that 95% of respondents using aids and adaptations felt that this had a positive impact on their quality of life and 79% of survey respondents said aids and adaptations improved their ability to be independent.
What can you do…
- Make your patients aware that this support is available from their local authority – in our survey only 15% of people with arthritis were aware of the duty of the local authority to provide aids and adaptations.
- Find out the contact details of the relevant local authority and any local services that provide aids and adaptations so you can signpost your patients during consultation.
For further information about why aids and adaptations matter to people with arthritis you can read our recently published report ‘Room to Manoeuvre’ (PDF, 812 KB).
Improving musculoskeletal health at work: part of the new NHS health and wellbeing framework
We are pleased to announce that the new NHS Workforce Health and Wellbeing Framework is now available. Versus Arthritis has supported the development of this tool by sharing best practice, research and insights.
The framework will support NHS organisations to improve the health and wellbeing of their staff through an easy to use diagnostic tool and a comprehensive range of guidance against fourteen core organisational enablers and health interventions proven to improve staff health and wellbeing. This will enable NHS organisations to develop comprehensive health and wellbeing plans and evaluate improvement over time.
The framework and diagnostic tool have been designed to be used in a flexible way to meet the needs of an organisation. The framework is divided into two sections, organisational enablers and health interventions with a focus on three health areas – mental health, musculoskeletal and healthy lifestyles. The diagnostic tool has been created to help assess an organisation against the Health and Wellbeing Framework. Through a series of questions, the tool allows for quick identification of the areas on which to focus in order to improve health and wellbeing in an organisation.
The young people and families service
The young people and families service started supporting young people with arthritis and their families in Northern Ireland more than 20 years ago. It has gradually grown across all four nations.
Relationships with health professionals are critical to the success of the service. These partnerships range from us delivering information sessions in clinic waiting areas, to having honorary contracts with specialist paediatric rheumatology clinics, and co-facilitating workshops and support sessions with nurses, OT’s and physios.
But meeting young people with arthritis in a hospital environment is not enough.
With an prevalence of 1:1000, young people with arthritis are unlikely to meet another young person with a similar condition by chance.
"It was the best thing I could have done to come to events. It has boosted my confidence, I am happier and more comfortable with my condition."
At an event 83% reported they have not had the opportunity to meet other young people living with arthritis before. The emotional impact of this is huge, they described this as making them feel disappointed, lonely and unsure.
To help young people and their families feel less isolated we provide peer support opportunities through a variety of events. These include;
- Residential activity weekends where young people have the opportunity to engage in activities from archery to zip-wiring
- Workshops covering issues such as self management, education/careers, communication, relationships and sexual health (Scotland only)
- Family events where the whole family are invited to participate.
All our events are supported by a team of fully trained peer support volunteers who have a lived experience of arthritis.
Events are open to 10-25 year olds with arthritis, the specific age range and events available varies across the nations.
- England 12–18 Years email@example.com
- Northern Ireland Up to 18 Years firstname.lastname@example.org
- Scotland 10-25 Years email@example.com
- Wales 10-18 Years firstname.lastname@example.org
Young people can self-refer to the service or be referred by a carer or professional with their agreement.
You can find details of the services using our face to face services finder.