Pathway

 

Aims of the Shoulder Pathway:

The pathway is for patients with shoulder pain and is aimed at making the care journey as effective and efficient as possible by providing guidance to general practitioners, consultants and other health care professionals.

Management in primary Care:

Patients with shoulder pain should initially have red flags excluded.  These include:

Fractures and Dislocations

These patients will present with a history of recent trauma, unusual deformity, swelling and joint effusion.  They should be referred to  A&E.

Infection

These patients  will present with symptoms suggestive of septic arthritis, e.g. fever or chills and hot and swollen joints.  They should be referred to A and E.

Malignancy

These patients will have a previous history of cancer or suspected malignancy, unexplained deformity, lymphadenopathy, weight loss and night pain.  Investigations should be considered and referral onto the 2 week wait pathway if appropriate.

Neurological Lesion or Cervical Pathology

These patients will present with unexplained wasting, significant sensory or motor deficits, neurovascular compromise and pain associated with neck movement.  Depending on the severity these individuals should be referred to Physiotherapy, Neurology or A and E if a suspected stroke.

Polymyalgia Rheumatica

These patients tend to be over 50 years old and will have had symptoms for over 2 weeks, bilateral in nature and possibly with pelvic girdle aching, morning stiffness lasting over 45 minutes and evidence of an acute phase response.

Once the red flags have been cleared patients should be checked for calcific bursitis.  Subjectively these patients will have acute, severe, burning pain. Objectively this will be reproduced on palpation beneath the acromion, compression of the glenohumeral joint with relief from distraction and pain on passive range of movement but without a capsular pattern. This should be treated with heat or cold, be supplied with non-steroidal anti-inflammatory’s (NSAIDs) or a steroid injection and an x-ray should be considered with a referral to trauma and orthopaedics if after 3 months.

Objective Assessment

The objective assessment should be done in standing, sitting or lying and in the first instance the neck should be cleared.  Initially the patient should be assessed for significantly reduced passive/supported rotation.

Patients Presenting with Significantly Reduced Passive / Supported Rotation

An x-ray should be performed both AP and axillary to eliminate dislocation and differentiate glenohumeral osteoarthritis from a frozen shoulder.  The following pathways should be followed:

  • Chronically dislocated shoulders should be referred to trauma and orthopaedics
  • Glenohumeral arthritis should be prescribed NSAID’s or given a steroid injection (2 injections at least 6 weeks apart) as required to manage pain and a referral to physiotherapy should be considered. 
  • Frozen shoulders should follow the same pathway as glenohumeral arthritis.

Patients who do not present with significantly reduced passive/supported rotation should be tested for muscle strength and a weakness of abduction.

Patients Presenting with Weak/Painful Abduction

These patients have an subacromial impingement or cuff pathology. The following pathway should be followed:

  • With a history of trauma should be referred to Physiotherapy and trauma and orthopaedics
  • Where there is no trauma use NSAIDs or a sub acromial steroid injection (2 injections at least 6 weeks apart) to manage pain and refer to physiotherapy.

Patients without Weak/Painful Abduction

These patients fall into 1 of 3 categories:

  • Biceps tendonitis, presenting with anterior shoulder tenderness corresponding to the long head of biceps.  With these patients use NSAIDs or a sub acromial steroid injection (2 injections at least 6 weeks apart) to manage pain and refer to physiotherapy.
  • Acromio-claviciular arthritis, presenting with pain on the acromio-clavicular joint and/or cross-body abduction.  These patients should be managed the same as for biceps tendonitis.
  • Instability, where there is trauma refer to trauma and orthopaedics and where no trauma refer to physiotherapy.

If in doubt refer to physiotherapy.

How to access the service:

Response times & Prioritisation:

  • All  patients referred into this service will be seen and assessed by a senior Physiotherapist within 2 working days of receipt of referral.
  • Patients who need to be seen more urgently will be seen within 10 working days and all other patients within 20 working days.

Objective Measures:

  • All patients entering the pathway will complete an EQ5D and an Oxford Shoulder Score
  • This is repeated again once they are discharged from the service
  • We also use a patient satisfaction survey to gain patient feedback on the service.

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