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GP triage – Shoulder Menu

Common Shoulder Conditions
OA Shoulder
Affected Area
  • Gradual onset of stiffness and pain, worse with movement
  • Morning Stiffness < 30 minutes
  • Disturbed Sleep
  • Crepitus
  • Elderly population
  • Explanation & advice on activity and ADL
  • Regular simple analgesia
  • Physiotherapy
  • Consider single intra-articular injection x1  (only if not considering surgery and in significant pain)
  • X-ray: AP/axillary view
  • Not responding to treatment
  • Functional disability significantly affecting work and ADL
  • Patient would consider surgery and  understands that surgery is mainly a pain relief measure.
Shoulder Impingement​
Affected Area
  • Painful arc mid-range
  • Catches of pain
  • Pain over deltoid
  • Sleep disturbance (lying on
    affected side)
  • Worse in elevation
  • Affecting work or ADL
  • Most commonly affects middle aged patients
  • Education & advice
  • Exercise
  • Simple analgesics
  • NSAIDS
  • Physio referral for patients > 6/52
  • Consider a single steroid injection
  • X-ray: AP/axillary view
  • Refer to Ortho
  • Not responding to conservative treatment > 6 months duration (PT and steroid injection)
  • Functional disability significantly affecting work and ADL
  • Consideration of Arthroscopic SAD
  • Refer to MSK service/ Physio
  • Struggling with ADLs/ work/ conservative treatments.
Acromioclavicular joint
Affected Area
  • Pain felt over the top of shoulder over ACJ
  • Painful arc above 150°
  • Painful cross body flexion & high flexion/abduction
  • May have history of fall ,on to shoulder
  • May have ACJ deformity
  • Education & advice
  • Exercise
  • Simple analgesics
  • NSAIDS
  • Physio referral
  • Consider a steroid injection to ACJ
  • X-ray: AP/axillary view together with ACJ view
  • Not responding to treatment including steroid injection after 2-3 months
Adhesive Capsulitis​
Affected Area
  • Global loss of movement actively and passively, especially external rotation and elevation
  • Variable pain presentations depending on stage
  • Sleep disturbance
  • Usually age>40
  • Education & advice – Some will be happy with watchful waiting for up to 18/12 -function returns in 80% of cases.
  • Exercise
  • Simple analgesics
  • NSAIDS
  • Physio referral
  • Consider GHJ injection x1
  • X-ray: AP/axillary view
  • Not responding to treatment.
  • If no response to injection – consider secondary care for hydrodilation or consideration of surgical intervention (MUA).
Shoulder Instability
Affected Area
  • History of dislocation / subluxation
  • May be traumatic or non-trauma (hyperlaxity)
  • Education & advice
  • Exercise
  • Simple analgesics
  • NSAIDS
  • Physio referral for patients > 6/52
  • Consider a single steroid injection
  • X-ray: AP/axillary view
  • Refer to MSK service – No response to conservative treatment.
  • Apprehension or true instability affecting ADL, work, sport
  • Refer to Ortho – If symptoms are the consequence of a trauma within past 3 months and patient not seen in fracture clinic 
Degenerative Cuff Tear​
Affected Area
  • Usually age >40
  • Inability to abduct shoulder (if large tear)
  • Painful arc in abduction 50-130°
  • Catches in certain positions
  • May have crepitus
  • May have drop arm weakness
  • Upper arm pain
  • Night pain
  • May  have impingement signs  
  • Education & advice
  • Exercise
  • Simple analgesics
  • NSAIDS
  • Physio referral
  • Consider a single
  • Sub-acromial steroid injection
  • X-ray: AP/axillary view
  • No response to treatment  and 1 x steroid injection after 3-6 months
  • If pain persistent and functionally limiting ?consideration for SAD/cuff repair
  • Refer to secondary care if: Ultrasound scan confirms tear and not responding to injection or physiotherapy
  • Ultrasound scan/MRI depending on surgeons preference.
Acute Cuff Tear
Affected Area
  • Sudden inability to abduct arm
  • History of trauma
  • Sudden inability to abduct arm
  • History of trauma
  • X-ray: AP/axillary view
  • Direct referral to secondary care
  • Ultrasound/MRI depending on surgeons preference.
Inflammatory Shoulder Pain
Affected Area
  • Painful swollen joint
  • ESR>30 Mono or polyarthropathy
  • Direct referral to rheumatology
  • Analgesia/NSAID
  • X-ray: AP/axillary view
  • Inflammatory blood screen, urate
  • Direct referral to rheumatology