REPORTS ON THE RHEUMATIC DISEASES SERIES 5

Hands On
Practical advice on management of rheumatic disease

MANAGEMENT OF SHOULDER DISORDERS

IN PRIMARY CARE
Caroline Mitchell, MD FRCGP DRCOG
Senior Lecturer/General Practitioner, Academic Unit of Primary Medical Care, University of
Sheffield/Community Sciences Centre, Northern General Hospital, Sheffield February 2008 No 14

Introduction symptoms. Thus, occupations which usually involve such

physical risk factors are associated with a higher risk of
Shoulder disorders cause pain, limit the ability to perform shoulder disorders. Recognised risk factors for adhesive
many routine activities, and can significantly disrupt sleep. capsulitis (‘frozen shoulder’) include diabetes and prolonged
Self-reported prevalence of shoulder pain is estimated at immobility, for example, after a stroke, after shoulder
between 16% and 26% in the general population.1 Shoulder trauma or surgery, or associated with cardiac disease or
disorders are the third most common primary care mus- surgery. In common with other painful musculoskeletal
culoskeletal presentation (after back and neck pain) and, disorders, psychosocial factors can influence outcomes such
while most people recover within 3 months, recurrence or as return to normal activities and work.6,7
chronic symptoms may occur in a significant proportion of
patients.2 Clinical assessment of the painful
Several clinical tests (e.g. Hawkins, Neer, Yergason, Speed) shoulder
have been described to aid diagnosis of shoulder disorders.
The consultation should take a holistic approach, which
However, research acknowledges a lack of consensus on
includes an assessment of the functional impact of the
diagnostic criteria and a lack of concordance in clinical
shoulder problem and explores psychosocial and occu-
assessment, even between musculoskeletal specialists.3,4
pational issues. Shoulder pain may arise from elsewhere, so
Furthermore, mixed shoulder disorders occur commonly
it is important to enquire about the general health of the
and over-differentiation between the numerous diagnostic
patient and symptoms arising from the neck, upper limbs,
categories is unlikely to alter usual primary care treatment
axillae and chest.
and follow up.5

This report will focus on a simplified classification of History

shoulder disorder, differential diagnoses and referral The issues which should be covered are:
pointers based on a clinical assessment appropriate within • Determining the onset (acute, sub-acute, recurrent),
primary care. Treatment choices linked to this classification site, nature, exacerbating and relieving factors and any
are presented alongside a summary of the evidence for associated symptoms of the pain.
common interventions.
• Specifically enquiring about the relationship of the pain
to movement. Does it occur at rest? Is it nocturnal?
What are the risk factors?
• Is there difficulty sleeping on the affected side? While
Both incidence and functional impact increase with age. nocturnal pain may be due to difficulty finding a com-
Lifting heavy loads, repetitive movements in awkward fortable sleeping position, consider nerve root pain,
positions and/or prolonged elevation of the upper limb(s) bony pain or malignancy, particularly if there is a history
are all associated with the development of shoulder of cancer and/or systemic symptoms.

Medical Editor: Louise Warburton, GP. Production Editor: Frances Mawer (arc). ISSN 1741-833X.
Published 3 times a year by the Arthritis Research Campaign, Copeman House, St Mary’s Court, St Mary’s Gate
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• What is the impact on function of the joint? What
activities are impaired? Supraspinatus muscle
• Is the dominant or non-dominant arm affected?
Acromioclavicular joint
• Is there neck or other upper limb pain?
• Are any other joints affected? Clavicle
Acromion
• Is there any history of injury, acute shoulder pain or Coracoid
instability? Does the shoulder ever partly or completely process
come out of joint or is there concern that it might slip on
certain movements?
Scapula
• Enquiring about tasks undertaken at work and sporting
activities.
Humerus
• Are there systemic symptoms of illness (fever, night
sweats, weight loss, generalised joint pains, rash, new
respiratory symptoms)? FIGURE 1. The anatomy of the shoulder.
• Is there a past history of shoulder pain or other mus-
culoskeletal problems? What was the response to treat-
ment? TABLE 2. Shoulder pain: red flag indicators.
• Enquiring about significant co-morbidity (diabetes, • Tumour: history of cancer; symptoms and signs
stroke, cancer; respiratory, gastrointestinal, or renal dis- of cancer; unexplained deformity, mass, or
ease; ischaemic heart disease). swelling, lymphadenopathy
• Checking current drug treatment and adverse drug • Infection: red skin, fever, systemically unwell
reactions. • Unreduced dislocation: trauma, epileptic fit,
electric shock; loss of rotation; abnormal shape
Examination • Acute rotator cuff tear: recent trauma, acute
The normal shoulder joint has the greatest range of disabling pain and significant weakness, positive
movement of any joint. Assess active, passive and resisted drop arm test
movement in flexion, extension, abduction, adduction, and • Neurological lesion: unexplained wasting,
internal and external rotation. Examine the neck, upper significant sensory or motor deficit
limbs, axillae and chest wall for potential sources of referred
pain (Table 1).
Investigations
While plain radiography may be entirely appropriate to ex-
TABLE 1. Examination of the shoulder joint. clude fracture and/or dislocation in the context of trauma,
• Inspect shoulders from the front, from the side it is not usually indicated in the primary care assessment
and from behind for muscle wasting, swelling and of shoulder pain, unless, for example, malignancy is sus-
deformity. pected. Malignancy and systemic illnesses are relatively rare
• Examine the neck, axillae, and chest wall and for causes of shoulder pain, thus blood tests (full blood count,
lymphadenopathy. erythrocyte sedimentation rate) should likewise only be
• Assess range of movement of cervical spine. requested if there are red flag indicators.
• Palpate sternoclavicular, acromioclavicular and
glenohumeral joints for tenderness, swelling, Causes of shoulder pain
warmth and crepitus. Diagnosis should be based on a clinical assessment, sum-
• Compare power, stability and range of movement marised in the clinical algorithm opposite, which groups
(active, passive, resisted) of both shoulders. patients according to the most common presentations.
• Observe scapular movement.
• Look for a painful arc (70–120° active abduction). The causes of shoulder pain may usefully be divided into
• Test passive external rotation (less than 50% range conditions associated with pain arising from the shoulder
of movement compared to the unaffected side joint and those conditions where the pain arises from
suggests a glenohumeral problem). elsewhere (Table 3). This report will summarise the diag-
• Test for a significant rotator cuff tear (‘drop arm nosis and management of the three commonest shoulder
test’ – patient unable to support the weight of the disorders presenting to primary care physicians: rotator
affected arm abducted to 90°). cuff disorders, glenohumeral joint problems and acromio-
clavicular joint problems. Referred mechanical neck pain
is usually easily differentiated from a shoulder disorder as
Red flag indicators the pain and tenderness are localised to the neck and the
Red flag indicators include symptoms and signs of systemic suprascapular area and referred to the shoulder and arm,
disease, generalised or localised lymphadenopathy, history and also may be associated with upper limb paraesthesia.
of cancer, unexplained significant neurological deficit, and Movement of the cervical spine and shoulder usually
concerning local features such as a palpable mass or bony produces more generalised upper back, neck and shoulder
tenderness (Table 2). discomfort.

2
FIGURE 2. Diagnosis of shoulder problems
with guidelines for initial management

RED FLAGS –
Neck or shoulder or other?
Neck/arm urgent referral
Neck
s Symptoms localised to neck or shoulder? Shoulder See Table 2
s Move the neck and then
the shoulder
s Does this reproduce the pain?

Neck Shoulder Other neck or arm

Common age 35+ Common age 35+

Management History of instability? Management

s Perform neurological s Has your shoulder ever partly or s Rest s NSAIDs s Physiotherapy
examination. If positive completely come out of joint?
findings then refer s Are you worried that your shoulder
s Rest may dislocate or slip in the joint
s NSAIDs/analgesia
Instability
on sporting activity or on certain Yes
s Physiotherapy movements? Common age 10–35 years
to one
or both
Management
No
to both s Refer s Surgery

Acromioclavicular joint
Pain localised to the Yes disease (uncommon)
acromioclavicular joint and Common age 30–50 years
associated with tenderness?
Management
(there may be swelling) s Refer
s Rest
s NSAIDs/analgesia s Surgery
s Consider cortisone
No injection

Glenohumeral joint
Reduced passive external Yes
Frozen shoulder Common age 40–60 years
rotation? Arthritis (uncommon) Common age 60+

Management
s Rest s Cortisone injection
No s NSAIDs/analgesia s Refer
s X-ray s Surgery

Pain on abduction with the Rotator cuff/impingement

Yes
Common age 35–75 years
thumb down?
Management
Worse against resistance? s Rest s Consider
s NSAIDs/analgesia physiotherapy
Painful arc? s Cortisone injection s Refer
s Surgery

No

Other neck or arm pain Management Adapted with kind permission of the
s Rest s Physiotherapy Oxford Shoulder and Elbow Clinic,
Common age 35–75 years
s NSAIDs/analgesia s Refer Nuffield Orthopaedic Centre NHS Trust, Oxford

3
 prevalence of abnormalities, including partial and full
TABLE 3. Causes of shoulder pain.
thickness tears. Thus there may be little or no correlation
Pain arising from the shoulder between symptoms and functional impairment and the
• Rotator cuff disorders: rotator cuff tendinopathy, type and severity of the tear.9
calcific tendinitis, impingement, subacromial
bursitis, rotator cuff tears Glenohumeral joint problems
• Glenohumeral joint problems: capsulitis (‘frozen Adhesive capsulitis (‘frozen shoulder’) and glenohumeral
shoulder’), arthritis arthritis are characterised by deep joint pain, which causes
• Acromioclavicular joint problems significant restriction of activities of daily living due to
• Infection (rare) impaired external rotation, for example putting on a jacket.
• Traumatic dislocation Sleep is often disturbed. In adhesive capsulitis, three phases
may be described over a period of 18–24 months:
Pain arising from elsewhere
• Referred pain: neck pain, myocardial ischaemia, 1. initial, gradual onset of diffuse and severe shoulder
referred diaphragmatic pain
pain, typically worse at night with inability to lie on the
• Polymyalgia rheumatica affected side
• Malignancy: apical lung cancers, metastases
2. a stiff phase with less severe pain present at the end
range of movement, global stiffness and severe loss of
Common shoulder disorders shoulder movement
3. finally, a recovery phase with a gradual return of move-
Rotator cuff disorders ment.
In all rotator cuff disorders (Table 3), there is significant over-
During the stiffening phase of the process, the joint capsule
lap of presenting symptoms and signs. The rationale for
thickens and becomes stiff, rather like scar tissue. It is
grouping these disorders together is that treatment, man-
physically difficult to penetrate at arthroscopy.10
agement and follow up are similar.
Typically, there is significant restriction (over 50%) of passive
Rotator cuff tendinopathy is the most common cause of
external rotation, compared to the unaffected shoulder.
shoulder pain.5 There is often a history of physical risk factors
Overall, global pain and restriction of all active and passive
associated with occupational or sporting activities and pain
movements are present.
with overhead upper limb movements. Inspection may
reveal muscle wasting. On examination, pain is reproduced
Acromioclavicular joint problems
on abduction with the thumb down and is worse against
Acromioclavicular disorders in younger people are usually
resistance. While active and resisted movements are painful
secondary to injury, and sometimes joint dislocation may
and may be partially restricted, passive movements tend to
occur. Acromioclavicular osteoarthritis may be the cause
be full. The presence of a painful arc reinforces the diagnosis
of localised symptoms in the elderly, and in this age group
of a rotator cuff disorder, but research has suggested that it
may also be associated with rotator cuff disorders such as
is neither specific nor sensitive as a clinical sign.8
subacromial impingement and tendinopathy. Pain, tender-
The age of the patient, the mode of onset and character ness and occasionally swelling are localised to the acromio-
of the pain (acute or subacute onset, history of trauma), clavicular joint. There is restriction of passive horizontal
and functional impairment (exacerbation with overhead adduction (flexion) of the shoulder, with the elbow extended
activities and painful weakness of shoulder movements) across the body.
may indicate a diagnosis of rotator cuff tear rather than
tendinopathy. In young people there is usually a history of
acute onset after trauma. In the elderly, a rotator cuff tear Treatment
may be atraumatic, related to intrinsic degeneration of the
For all shoulder disorders recommend regular analgesia,
cuff or to attrition from bony spurs on the undersurface
encourage the patient to maintain activity (within limits),
of the acromion, or secondary to inflammatory arthritis.
advise on occupational issues and provide written ‘self-help’
A partial tear may exhibit similar features on clinical
information. Paracetamol is suitable as a first-line treatment
examination to rotator cuff tendinopathy (muscle wasting
and may be supplemented by mild opiates such as codeine
and painful weakness in resisted abduction may occur in
phosphate. If no contraindications exist, non-steroidal anti-
either condition). The ‘drop arm test’ (Table 1) has been
inflammatory drugs (NSAIDs) may be used short term. In the
described as a useful test for a large or complete tear and
elderly, specifically counsel about the increased risk of upper
is an easy technique to incorporate into examination of the
gastrointestinal side-effects and impact on renal function
joint.8
and cardiovascular risk with NSAIDs, and in all patients the
A study which used magnetic resonance imaging of the risks of dependence and constipation with regular opiate
shoulder joint in asymptomatic individuals found a high analgesics.

4
 Practical tips
Useful patient information:
• Arthritis Research Campaign information booklet, ‘The Painful Shoulder’:
www.arc.org.uk/arthinfo/patpubs/6039/6039.asp
• NHS Direct: www.nhsdirect.nhs.uk
Specialist/occupational health information:
• Work-related disorders of the upper limb. Reports on the Rheumatic Diseases (Series 5),
Topical Reviews 10. Arthritis Research Campaign; 2006 Oct:
www.arc.org.uk/arthinfo/medpubs/6630/6630.asp
• The Health and Safety Executive website provides useful guidelines for employers:
www.hse.gov.uk/msd/hsemsd.htm#uld

Rotator cuff disorders ponse is good, the injections could be repeated up to three
While relative rest in the early stages is appropriate for times, at 6-weekly intervals. As there is no evidence that ster-
rotator cuff disorders (including possible minor tears), the oid injections are either beneficial or harmful in the pres-
patient should aim to return to normal activity as soon as ence of a rotator cuff tear, they should be avoided if the his-
possible. Attention to occupational factors is important in tory and examination suggest a large or complete tear.
order to reduce the risk of long-term incapacity and loss
of employment. Changes may need to be made within the Glenohumeral joint problems
workplace in order to facilitate early return to work, for The classical history of adhesive capsulitis is resolution after
example a phased return to work or a temporary respite 18–24 months, although symptoms may persist for 3 years
from work involving repetitive shoulder movements or or more, particularly in diabetic patients. The mainstay of
heavy lifting. management is pain relief and maintenance of function,
and treatment can be tailored to the presenting phase. For
Overall there is a lack of high-quality clinical trial evidence for example, active physiotherapy alone may be distressing
common primary care treatments for rotator cuff disorders. and counterproductive if started in the early, painful phase
Many of the studies have been undertaken in a secondary of the condition, but starting soon after intra-articular
care setting and involved complex interventions which are corticosteroid injections may be of short-term benefit.13
not easily reproduced in primary care. In a primary care Gentle mobilisation and strengthening exercises may
population, participants presenting with undifferentiated improve mobility and reduce disability in the later phases.
shoulder disorders who were allocated to a physiotherapy
treatment group were less likely to re-consult with a GP than Test your knowledge
those receiving steroid injections alone.11 ‘Frozen shoulder (adhesive capsulitis)’: an on-line
learning module, including a short test and a
Systematic reviews suggest equivalent short-term benefit for
certificate to include in a personal development
physiotherapy (incorporating supervised exercise) and ster-
plan. www.bmjlearning.com
oid injections in the management of shoulder disorders.12
Subacromial corticosteroid injections (see British National
Formulary www.bnf.org/bnf/), up to 10 ml in volume, may Acromioclavicular joint problems
relieve pain and thus facilitate rehabilitation, but the effect If there is significant traumatic dislocation, refer the
may be small and relatively short-lived.12 If the initial res- patient. Otherwise, complete resolution of symptoms is
usual following rest and simple analgesia. Consider ster-
oid injection of the joint if symptoms persist despite con-
servative management.
Rotator cuff
Acromioclavicular Other interventions
joint
Clinical trials of acupuncture treatment for shoulder prob-
lems have tended to be too small and methodologically
Coracoid diverse to provide robust evidence of benefit, apart from
(a) process
some short-term pain relief after treatment. Occupational
factors have been implicated in the development of shoulder
disorders and there is evidence that the prognosis of both
neck pain and low back pain are influenced by individual
psychosocial factors (general psychological distress, fear of
(b) movement, passive coping style). However, a systematic
review of a limited evidence base found multidisciplinary
FIGURE 3. Injection of the shoulder joint:
biopsychosocial rehabilitation for shoulder problems in
(a) subacromial approach, (b) anterior approach.
adults of working age no better than ‘usual care’.14

5
Referral criteria References
1. Urwin M, Symmons D, Allison T et al. Estimating the burden of
The patient should be referred to an orthopaedic specialist musculoskeletal disorders in the community: the comparative
if there is: prevalence of symptoms at different anatomical sites, and the
relation to social deprivation. Ann Rheum Dis 1998;57(11):649-55.
• diagnostic uncertainty or any of the red flag criteria 2. Winters JC, Sobel JS, Groenier KH, Arendzen JH, Meyboom-de Jong B.
summarised in Table 2 The long-term course of shoulder complaints: a prospective study
• history of shoulder joint instability in general practice. Rheumatology (Oxford) 1999;38(2):160-3.
3. Bamji AN, Erhardt CC, Price TR, Williams PL. The painful shoulder:
• acute, severe post-traumatic acromioclavicular pain can consultants agree? Br J Rheumatol 1996;35(11):1172-4.
• pain and significant disability lasting more than 6 4. de Winter AF, Jans MP, Scholten RJ, Deville W, van Schaardenburg
months, despite attention to known physical risk factors D, Bouter LM. Diagnostic classification of shoulder disorders:
and, if indicated, treatment with physiotherapy and interobserver agreement and determinants of disagreement. Ann
steroid injections. Rheum Dis 1999;58(5):272-7.
5. Ostor AJ, Richards CA, Prevost AT et al. Diagnosis and relation to
general health of shoulder disorders presenting to primary care.
KEY PRACTICE POINTS Rheumatology (Oxford) 2005;44(6):800-5.
6. Bergenudd H, Lindgarde F, Nilsson B, Petersson CJ. Shoulder pain
• Self-help advice and discussion of physical in middle age: a study of prevalence and relation to occupational
contributory factors should be provided, in work load and psychosocial factors. Clin Orthop Relat Res 1988;
addition to analgesics. (231):234-8.
7. Bongers PM. The cost of shoulder pain at work. BMJ 2001;322
• Referral for physiotherapy may improve short- (7278):64-5.
term outcomes and reduce GP consultations for 8. Calis M, Akgun K, Birtane M, Karacan I, Calis H, Tuzun F. Diagnostic
shoulder pain. values of clinical diagnostic tests in subacromial impingement
• Steroid injections have a marginal short-term syndrome. Ann Rheum Dis 2000;59(1):44-7.
effect on pain. 9. Sher JS, Uribe JW, Posada A, Murphy BJ, Zlatkin MB. Abnormal
findings on magnetic resonance images of asymptomatic shoulders.
• Mild trauma or overuse (before the onset of J Bone Joint Surg Am 1995;77(1):10-5.
pain), early presentation and acute onset have 10. Norlin R. Frozen shoulder: etiology, pathogenesis and natural
a more favourable prognosis. course. www.shoulderdoc.co.uk 2005 Oct 13.

• Poorer prognosis is associated with increasing 11. Hay EM, Thomas E, Paterson SM, Dziedzic K, Croft PR. A pragmatic
randomised controlled trial of local corticosteroid injection and
age, diabetes, severe or recurrent symptoms at
physiotherapy for the treatment of new episodes of unilateral
presentation, and associated neck pain. shoulder pain in primary care. Ann Rheum Dis 2003;62(5):394-9.
• Consider orthopaedic referral for surgical 12. Buchbinder R, Green S, Youd JM. Corticosteroid injections for
assessment when primary care measures fail. shoulder pain. Cochrane Database Syst Rev 2003;(1):CD004016.
13. Carette S, Moffet H, Tardif J et al. Intraarticular corticosteroids,
supervised physiotherapy, or a combination of the two in the
treatment of adhesive capsulitis of the shoulder: a placebo-
Acknowledgement controlled trial. Arthritis Rheum 2003;48(3):829-38.
This paper (including the tables) is derived from the following clinical 14. Karjalainen K, Malmivaara A, van Tulder M et al. Multidisciplinary
review: Mitchell C, Adebajo A, Hay E, Carr A. Shoulder pain: diagnosis biopsychosocial rehabilitation for neck and shoulder pain
and management in primary care. BMJ 2005;331(7525):1124-8. www. among working age adults. Cochrane Database Syst Rev 2003(2):
bmj.com/cgi/content/full/331/7525/1124. CD002194.

6
COMMENT Andrew J Carr, MA, ChM, FRCS
Nuffield Professor of Orthopaedic Surgery

Shoulder pain is a very common cause of disability in A large number of questions about shoulder disorders
the community. To a large extent it has been overlooked remain unanswered, for example:
both in terms of the amount of morbidity it causes 1. Can a better treatment for frozen shoulder be
and also in terms of how it should best be managed. found – for example are new anti-inflammatory
This excellent overview summarises the approach to the
medications going to be useful?
management of shoulder pain in primary care. It dis-
2. How many injections should be given into the
tinguishes the different types and patterns of shoulder
subacromial bursa or shoulder joint before they
pain and provides guidelines for early management.
Significantly it distinguishes conditions involving the cause damage to tendon or other tissue?
rotator cuff (impingement and rotator cuff tear) from 3. Is accurate placement of an injection using ultra-
disorders of the glenohumeral joint (frozen shoulder) sound guidance a better way of managing dis-
and osteoarthritis. The management strategy of these orders of the subacromial bursa and rotator cuff?
conditions is different and it is important for doctors 4. What is the best timing of management for ro-
in primary care to be able to distinguish them. This can tator cuff tears? Should early surgery be advocated
be done fairly straightforwardly with simple attention to prevent progression and the development of
to aspects of examination in the surgery. In primary unmanageable massive tears?
care complicated imaging is rarely needed for shoulder
disorders and is best left to severe cases or cases which Further research into both the natural history inves-
fail to respond to treatment and need management tigation and treatment of disorders including impinge-
in secondary care. A substantial number of operative ment, rotator cuff tear and osteoarthritis is currently
procedures are now available for shoulder disorders being supported by the Arthritis Research Campaign
and the review provides advice about the best time to (arc) and should allow us to give better advice to
refer patients to secondary care. patients in the future.

This issue of ‘Hands On’ can be downloaded as html or a PDF file from the Arthritis Research
Campaign website (www.arc.org.uk/about_arth/rdr5.htm and follow the links).

Hard copies of this and all other arc publications are obtainable via the on-line ordering system
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7
 2008 BSR Annual Meeting, Liverpool
Primary Care Day : 22 April 2008

SHOULDER PAIN
The British Society for Rheumatology, Primary Care Rheumatology Society and the arc Primary
Care Working Group are running a combined educational day on shoulder pain aimed at GPs,
rheumatologists and health professionals in rheumatology.

Topics include:
• Functional anatomy of the shoulder and common shoulder problems
• ‘Hands on’ examination session
• Operative treatment of shoulder problems
• Imaging of the shoulder – including a practical demonstration of
musculoskeletal ultrasound
• Sports injuries affecting the shoulder and their treatment/rehabilitation

For full details visit:

www.bsrconference.org.uk/primarycareday.html

Are you or do you know a GP registrar

with an interest in rheumatology?
Did you know about the
arc GP Registrar Prize?
One in five patients we see has a problem related to their
musculoskeletal system and arc is keen to foster interest
in this area in our future GPs. Audits, reports of service
developments and case studies are welcome entries.

Entries in by 7 JULY 2008. For an entry form and further

information please go to the arc website at:
www.arc-research.org.uk/forms/arcgpregistrarprize.asp