Shoulder / Elbow pain- Adult Leeds

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1.  Background Information / Scope of Pathway

Quick info:
These pathways were developed to guide clinicians when managing adults with common musculoskeletal problems. The pathways are not provider specific and so the guidance and forms apply to all providers.

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2.  Information Resources for Patients and Carers

Quick info:
Patient information
MSK TAS Patient Information Leaflet

Shoulder Impingement patient information leaflet

Shoulder Instability patient information leaflet

Frozen Shoulder patient information leaflet

Olecranon Bursitis information leaflet

Tennis Elbow information leaflet

Golfers Elbow patient information leaflet

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3.  Development & Updates to this Pathway

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Development
The pathway redesign was a clinically lead city wide process. It was conducted through the Musculoskeletal Steering Group

which had representation from the 3 CCGs, Patients, NHS Leeds, Leeds Teaching Hospitals Trust and the Leeds Musculoskeletal Services.

The individual pathways were authored by the appropriate clinical staff involved in delivering the pathway, but chiefly comprised of GPs, Consultants and Therapists.

The pathways went live on the 2/7/2012

Updates

Referrals Forms Updated October 2012.

Major Review and Update June 2013
This involved reformating of the pathway and referral forms.

Updated January 2016

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4.  Referral Forms

Quick info:
Referral Forms

Quick View - PDF
MSK11 Shoulder-Elbow Pain V3
MSK14 Problem Not on Pathway Form V3

Mailed Merged
The forms below are provided as a repository. They can be downloaded to your computer and be imported to your clinical system. This is so all practices have access to the most up to date forms.

EMIS - merged
MSK11 Shoulder-Elbow Pain V3
MSK14 Problem Not on Pathway Form V3

SystmOne - merged
MSK11 Shoulder-Elbow Pain V3
MSK14 Problem Not on Pathway Form V3

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6.  Red Flag Symptoms - manage as per suspected pathology

Quick info:
GP information
Acute shoulder pain may be the first warning signs of serious disease. Although uncommon, the following should be considered:

  • Tumours – 7% of bony metastases occur in the proximal humerus. There may be a history of neoplasia or of recent weight loss or malaise.
  • Inflammatory Arthropathy   For example, Rheumatoid Arthritis, Gout or Polymyalgia Rheumatica. There may be other associated symptoms and signs or systemic illness.
  • Fracture or Dislocation – There is usually a history of trauma.
  • Referred Pain – The commonest cause of referred shoulder pain is cervical spondylosis but other causes such as apical lung tumour or a cause of diaphragmatic irritation such as subphrenic abscess or gall bladder disease should be considered. Mediastinal pathology such as ischemic heart disease should also be excluded.

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7.  Shoulder Pain

Quick info:
GP information
Subacromial impingement syndrome (SAIS)
Presentation:

  • age 40-60
  • pain anteriorly and lateral to shoulder (often over deltoid area)
  • painful arc
  • pain commonly with reaching or with overhead activity
  • no pain radiating past elbow
  • nocturnal pain if rolls onto affected shoulder at night

Onset mostly insidious, occasionally related to ongoing pain following trauma. Most SAIS improves with rest from the aggravating activity although pain will commonly persist if not treated.

Assessment:

  • subjective assessment:
    • pain with overhead activities; movements of shoulder such as pushing reaching, pulling and lifting
  • objective assessment:
    • painful arc 90-120° shoulder flexion or abduction
    • positive impingement tests (Hawkins and Kennedy and empty can)
  • GP management:
    • prescribe appropriate analgesia
    • advise relative rest from aggravating activity
    • give impingement patient information leaflet
    • referral to MSK service
    • steroid injection
  • MSK management:
  • Treatments for SAIS may include:
    • education and advice
    • home exercise programme
    • manual therapy
    • subacromial steroid injection
    • postural education or exercise groups
  • Investigations:
    A diagnostic ultrasound or ultrasound guided injection may be performed by the MSK consultants for symptoms not responding to rehabilitation. Referral to Orthopaedics for a subacromial decompression may be required.
    Adhesive Capsulitis (frozen shoulder)
    Presentation:
    • age 30-55
    • frequently associated with diabetes
    • stiff and painful, often severe
    • nocturnal pain if roll onto affected side
    • no neurological symptoms

Onset of primary frozen shoulder is slow and insidious; secondary frozen shoulder may occur following a single traumatic event such as a fall on outstretched arm or from a pulling / traction injury.

Assessment:

  • subjective assessment:
    • pain at night; pain anterior shoulder (with severe frozen shoulder pain to wrist and hand), stiffness, difficulty dressing, etc
  • objective assessment:
    • stiff all directions especially external rotation
    • no crepitus
    • increased pain with movement eased with rest immediately
  • GP management:
    • prescribe appropriate analgesia
    • give patient "frozen shoulder" information leaflet
    • not usually investigated unless age>60 to exclude arthritis
    • early intra-articular injections advisable
    • refer to MSK team
  • MSK management:
  • Treatments for frozen shoulder may include:
    • education and advice
    • home exercise programme
    • manual therapy
    • intra-articular steroid injection to GH join
    • the MSK consultants provide high volume injections for those failing to self manage
    • onward referral to orthopaedics may be required for a capsular release or MUA

Shoulder Instability
Presentation:

  • more likely under the age of 40
  • often present as an ongoing impingement following dislocation due to structural instability or poor proprioceptive muscle control
  • onset is almost always traumatic

Assessment:

  • subjective assessment:
    • reports a dislocation; apprehensive about abduction and external rotation
  • objective assessment:
    • positive laxity tests (sulcus sign, and apprehension and relocation tests)

GP management:

  • Young dislocations, age<23 especially through sport: refer to orthopaedics
  • Multiple dislocations: refer to MSK service

MSK management:
Treatments for instability may include:

  • education and advice
  • rotator cuff strengthening
  • proprioceptive exercises
  • postural education
  • exercise class

Investigations:
An ultrasound may be performed for differential diagnosis with symptoms that do not respond to rehabilitation. An orthopaedic referral may by required if instability persists.
Other possible causes of shoulder pain for differential diagnosis:

  • Rotator cuff tears (positive Lag sign or drop-arm test)
  • Acromioclavicular joint pain (Positive Scarf test)
  • Pancoast tumour (apical lung tumour) – hoarseness, dyspnoea or cough
  • Osteoarthritis
  • Cervical spine nerve root irritation – posterior shoulder pain/whole area pain +/-paraesthesia/anaesthesia
  • Visceral shoulder pain
    • Angina = left shoulder tip pain
    • Gall bladder disease/liver = right shoulder pain
    • Subphrenic abscess = can present as severe rapid onset shoulder tip pain +/- unwell or abdominal symptoms.

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9.  Painful Arc / Shoulder Impingement

Quick info:
GP information
It is important to remember that the term ‘Painful Arc’ describes a clinical sign rather than a diagnosis. The clinical sign is discomfort / pain between 60-120° of shoulder abduction and classically implies impingement in the narrow space through which rotator cuff tendons pass between the head of the humerus and the acromion of the scapula.

The ‘Painful Arc’ sign may indicate a number of pathologies including rotator cuff (most commonly supraspinatus) tendinopathy

or tendon tear, calcifying tendinopathy, subacromial bursitis or bony abnormality (osteoarthritic spurs / congenital variations of the acromion). Weakness of humeral stabilising muscles (rotator cuff) relative to the humeral elevators (deltoid) may result in superior humeral head motion reproducing impingement. Scapular stabilising muscle weakness may produce inferior movement of the acromion also reproducing impingement.

Identifying severity:

  • An appreciation of the wide differential diagnosis of ‘Painful Arc’ is vital to ensure appropriate patient management.
  • It is also worth noting that this sign in a younger person may well indicate shoulder instability (possibly through mechanisms of relative shoulder muscle weakness described above) and failure to recognise and treat this will likely lead to poorer outcomes.
  • Suggested management of ‘Painful Arc’ involves determining which patients have mild symptoms and those with moderate/severe symptoms.
  • Patients with the following are most likely to fall into the moderate/severe category:
    • with a longer duration of symptoms
    • more severe pain requiring significant analgesia +/ - nocturnal pain (a classic sign of rotator cuff tear)
    • more severely restricted range of movement / weakness of resisted abduction

Patient management: Individuals with mild symptoms:

  • can be managed initially without referral or intervention, by providing self management information. Referral to Tier 1 physiotherapy is an option should symptoms persist

For individuals with moderate/severe symptoms:

  • it would be good practice to discuss with the patient the fact that the differential diagnosis is wide, and a number of management options exist
  • if local expertise exists, a GP unguided injection can be attempted if the patient consents and is aware that the treatment is offered without firm diagnosis
  • a further option to discuss with the patient is referral to radiology for ultrasound scan with the dual aim of securing a diagnosis and, if appropriate, offering treatment with a guided injection
  • the third option to discuss is referral to the MSK-MDT. This may be the most appropriate referral for younger patients in whom instability is suspected to be an underlying feature for a full assessment, or for those who decline unguided/guided injection. The MSK-MDT may also provide access to injections/physician ultrasound scanning
  • those patients who fail to respond to unguided or guided injection, or have recurrent symptoms would also be appropriate for MSK-MDT referral

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12. GP Advised Self-Management

Quick info:
Patient information
See attached patient information leaflet on shoulder impingement.

GP information
When a patient presents with shoulder pain and a painful arc, if the symptoms are relatively mild, a period of self-management is reasonable. This could involve:

  • analgesia as required
  • advice of use of ice packs
  • provision of the attached patient information leaflet
  • exercises (as demonstrated on the information leaflet)

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13. Refer to Tier 1 Physiotherapy Referral Form (MSK11)

Quick info:
Referral Form:
MSK11 Shoulder-Elbow Pain V3

Choose & Book
You can find this clinic on Choose & Book under:
Speciality: Physiotherapy
Clinic Type: Musculoskeletal

Provider information
The only provider of Tier 1 physiotherapy in the city is the Leeds Musculoskeletal Service. This service is directly bookable via Choose and Book. Please complete the appropriate form and send via Choose and Book.

If symptoms persist, referral to Tier 1 physiotherapy is appropriate, who will refer onward to MSK-MDT if symptoms persist or there is diagnostic doubt.

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14. Unguided Steroid Injection

Quick info:
This can be performed by GP in house if skills are available or alternatively refer to a minor surgery provider from this list available on e-Referral

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15. Ultrasound Scan Without Injection

Quick info:
If likely to alter management (for example to exclude rotator cuff tear)

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17. Refer to MSK-MDT Referral Form (MSK11)

Quick info:
Referral Form:
MSK11 Shoulder-Elbow Pain V3

Choose & Book
You can find this clinic on Choose & Book under:
Speciality: Orthopaedics
Clinic Type: Shoulder/Elbow

Provider information
The only provider of the MSK-MDT clinic in the city is the Leeds Musculoskeletal Service. This is a multiprofessional clinic including senior physiotherapists and musculoskeletal physicians.

This clinic provides diagnosis, investigation, treatment and onward referral if needed.

This service is directly bookable via Choose and Book. Please complete the appropriate form and send via Choose and Book.

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18. Refer for Ultrasound Guided Injection (Only After Physiotherapy and Unguided Injection Have Failed)

Quick info:
Refer only after failure of both physiotherapy and unguided injection.

Key Dates
Published: 14-Jan-2016, by Leeds
Valid until: 17-Feb-2017

References

This is a list of all the references that have passed critical appraisal for use in the care map MSK - Shoulder and Elbow pain

Reference

  1. American Academy of Orthopaedic Surgeons. AAOS clinical guideline on shoulder pain. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2001.

  2.  Australian Acute Musculoskeletal Guidelines Group. Acute Shoulder Pain. Canberra: National Health and Medical Research Council; 2003.

  3. Brigham and Women's Hospital. Upper extremity musculoskeletal disorders. A guide to prevention, diagnosis and treatment. Boston, MA: Brigham and Women's Hospital; 2006.

  4. Clinical Knowledge Summaries (CKS). Shoulder pain. Newcastle upon Tyne: CKS; 2008.

  5. Clinical Knowledge Summaries (CKS). Osteoarthritis. Newcastle upon Tyne: CKS; 2009.

  6. Dinnes J, Loveman E, McIntyre L et al. The effectiveness of diagnostic tests for the assessment of shoulder pain due to soft tissue disorders: a systematic review. Health Technol Assess 2003; 7: 1-185. http://www.ncchta.org/fullmono/mon729.pdf

  7. Gotzsche P. Non-steroidal anti-inflammatory drugs. Clin Evid 2002; 1203-1211.

  8. National Institute for Health and Clinical Excellence (NICE). Extracorporeal shockwave lithotripsy for calcific tendonitis (tendinopathy) of the shoulder. Interventional Procedure Guidance 21. London: NICE; 2003. http://www.nice.org.uk/nicemedia/pdf/ip/IPG021guidance.pdf

  9. New Zealand Guidelines Group. The diagnosis and management of soft tissue shoulder injuries and related disorders. Wellington: New Zealand Guidelines Group; 2004. http://www.nzgg.org.nz/guidelines/0083/040715_FINAL_Full_Shoulder_GL.pdf_1.pdf

  10. Speed C. Shoulder pain. Clin Evid 200

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