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GP triage – Shoulder Menu

Common Shoulder Problems

OA Shoulder
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
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
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
Global loss of movement actively and passively, especially external rotation and elevation 
Variable pain presentations depending on stage
Sleep disturbance
Usually age>40
Women>men
Poor prognosis in diabetes
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
History of dislocation/ subluxation
May be traumatic or non-trauma (hyperlaxity)
Education & Advice
Physio referral
Analgesia as required
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
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
Sudden inability to abduct arm 
History of trauma
Physiotherapy to maintain ROM
Surgical referral
X-ray: AP/axillary view
Direct referral to secondary care
Ultrasound/MRI depending on surgeons preference.
Inflammatory Shoulder Pain
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