Shoulder Pain
RADIOGRAPHS
NORMAL
Deltoid Region
Look, Feel, Move
Nocturnal
Reduced range of GHJ
Activity Related
Active v passive range
movement
No Parasthaesia
No Neurology
Frozen Shoulder
Pain Reduced
Movement
Impingement
Positive Tests
ABNORMAL ie red flags
Refer
Inject Sub-acromial Space
Physiotherapy
Pain Killers
Inject GHJ
Physiotherapy
Pain Killers
REVIEW 8/52
Assess Cuff
Impingement Tests
ACJ Tests
Improved
Not Improved
Instability Tests
C/Spine & Neurology
1
No Further Treatment
Refer
2
Impingement
ACJ Pain
Frozen Shoulder
GHJ Osteoarthritis
History
Pain Deltoid region,
affecting ADL, Sleep
Pain over the ACJ,
affecting ADL, Sleep
Signs
- ? Painful Arc
- Positive Scarf Test
- No weakness
- ROM Maintained
Treatment
Symptomatic
- Painful Arc
- Positive
impingement test –
Hawkins Kennedy
- No weakness
- ROM Maintained
Physiotherapy,
NSAID’s ,+/- injection
Pain Deltoid
Progressive Stiffness,
Sleep
- Global reduction of
movement
- Reduced external
rotation
- No weakness
Pain Deltoid,
Stiffness,
Sleep disturbance
- Global reduction of
movement
- Reduced external
rotation
- Crepitus
- No weakness
Physiotherapy,
NSAID’s
Investigations
AP Shoulder X-ray
AP Shoulder X-ray
Refer
If still symptomatic –
Consider further
injection (if previous
was beneficial)
If patient willing to
have surgery
Physiotherapy,
NSAID’s ,+/injection
Physiotherapy,
NSAID’s, +/- injection
AP Shoulder X-ray – If
Normal confirms
diagnosis
If still symptomatic
If still symptomatic –
– Consider further
Consider further
injection (if previous injection (if previous
was beneficial)
was beneficial)
If patient is willing
If patient willing to
to have surgery
have surgery
AP Shoulder X-ray GHJ OA
If patient willing to
have surgery to
reduce pain
Instability
Acute
Cuff Tear
Degenerative Cuff
Tear
Recurrent subluxation/
dislocation
Trauma,
Weakness
Often hyper-mobile,
No pain/ weakness
Weakness
on testing
Cuff
Physiotherapy for
subluxation.
Refer to secondary care
dislocation
none
Refer to
secondary
care
Weakness,
Pain,
Difficulty with ADL
- Weakness on testing
Cuff
- ? Positive
Impingement
- ? Reduced range of
movement
Physiotherapy, NSAID’s
1st time dislocators,
failed physio for
subluxation
AP shoulder
xray/Ultrasound if
referring
If patient willing to
have surgery
SYMPTOM SEVERITY
Mild
Moderate
Severe
Abnormal X-rays or Scans
Red Flag
Activity modification
Inject & Physiotherapy
Refer – if pt will consider surgery
Refer
Refer
Physiotherapy