Shoulder pain other causes- Adult Leeds

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1.  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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2.  Referral Forms

Quick info:
Referral Forms

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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4.  Wobbly Shoulder/ History of Traumatic Dislocation (NOT acute trauma)

Quick info:
GP information
The ‘wobbly shoulder’ pathway describes the presentation of shoulder instability. Whilst shoulder instability can be present without a history of trauma, this pathway is a guide to management of the condition following a history of traumatic dislocation in the past. Acute trauma of course requires emergency hospital assessment. Anterior dislocation is most common.

Clues to the presentation of this condition may include:

  • history of traumatic dislocation
  • persistent shoulder pain
  • ‘catching’ sensation in the shoulder
  • transient numbness or weakness of arm (traction/ impingement on neurovascular structures)
  • various clinical tests exist to assess shoulder instability, including the ‘apprehension-augmentation-relocation’ test for anterior instability, though extreme caution is advised if attempting such tests because it is possible to dislocate the shoulder if done incorrectly

If a patient presents in this way it is suggested that:

  • Those less than 23 years of age AND are keen sporting individual AND would consider surgery should be referred immediately to the MSK-MDT for assessment prior to surgical referral. These patients are most likely to benefit from surgical stabilisation.
  • For all others, it is reasonable to wait 3 months. During this time, the patient can be provided with self-management advice. Referral to Tier 1 physiotherapy is suggested if symptoms persist during this time period.

After 3 months if symptoms persist, or in the case of recurrent dislocation, a referral to MSK-MDT is advised for further evaluation and consideration of management options.

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5.  Acromioclavicular Joint Pain

Quick info:
GP information
Acromioclavicular joint pain:

  • may be secondary to degenerative change which is relatively common in those aged 40 years and above
  • may also follow trauma
  • generally felt on top of the shoulder, and usually well localised   on examination the joint is tender to palpation and symptoms are reproduced when the arm of the affected side is flexed to 90° and forcibly adducted across the chest (Scarf test)

Degenerative acromioclavicular joint pathology may be treated with injection of corticosteroid. If expertise exists in the practice, an unguided injection can be reasonably attempted. If symptoms do not settle or recur, it would be appropriate to refer to the MSK-MDT for further assessment.

If blind injection cannot be provided in the practice, or doubt exists regarding the diagnosis, another appropriate initial option would be referral to the MSK-MDT for consideration of unguided injection and further assessment and management.

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6.  Diagnosis Uncertain

Quick info:
GP information
A number of patients with shoulder pain will not fall into the categories defined on the pathway. Clearly it is important to exclude red flag causes of pain outlined elsewhere including tumours and infection, and non-musculoskeletal referred pain from diaphragmatic irritation and cardiac ischaemia for example.

If the precise diagnosis is uncertain but felt to be musculoskeletal in origin it is worth considering the following factors:

  • Where is the precise location of the pain? If not the shoulder, is it in fact closer to the neck, and what is the range of movement in the neck? Could this pain be referred from the cervical spine?
  • What is the range of movement of the shoulder? Is there a deficit of movement or power?
  • Is the pain persistent requiring regular analgesia, and how long has the patient suffered symptoms?

If the symptoms are of new-onset, mild and without loss of range of movement and power at the shoulder then a period of watchful waiting with appropriate analgesia may be indicated. If felt appropriate a referral could also be instigated to Tier 1 physiotherapy.

If symptoms are more severe, or persistent, or with loss of range of movement or power at the shoulder, referral to the MSK-MDT would be appropriate.

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7.  Problem Not on Pathway

Quick info:
There are 2 broad groups of patients who fall into this category:

Those who have a clear problem but there is no Leeds pathway and so you are ensure of where to refer the patient.

Those with a clear problem and course of action but you are unable to make the referral because of referral restrictions caused by some pathways still not allowing GPs to directly refer to the appropriate surgeon. Pathways where these restrictions still occur are the Shoulder / Elbow, Spine, Knee and Foot / Ankle.

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10. Refer to MSK-TAS (Telephone Assessment Service) Form (MSK14)

Quick info:
MSK TAS Patient Information Leaflet

Referral Form:
MSK14 Problem Not on Pathway Form V3

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

The MSK Telephone Assessment Service (MSK-TAS) is offered as a way of ensuring patients get into the right clinic when it is not clear from the pathways what the right course of action is.

This is distinct from the Diagnosis Unclear Pathway which is there to offer quick access to diagnostic assessment when patients present with symptoms that don't immediately fall into a diagnostic group.

Patients who are appropriate for the MSK-TAS fall into two categories:

Those who have a clear problem but there is no Leeds pathway and so you are ensure of where to refer the patient.

Those with a clear problem and course of action but you are unable to make the referral because of referral restrictions caused by some pathways still not allowing GPs to directly refer to the appropriate surgeon. Pathways where these restrictions still occur are the Shoulder / Elbow, Spine, Knee and Foot / Ankle.

When you book the patient into the MSK-TAS via Choose & Book you are booking them a telephone appointment.

Once the referral form has been completed and sent via Choose & Book a senior Physiotherapist will review the referral form within 48 hours. They will then decide the appropriate course of action and the patient will be contacted by phone at the allotted time in order to make the necessary arrangements for onward referral.

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12. Unguided or Ultrasound Guided Steroid Injection - Refer to MSK-MDT Referral Form (MSK11)

Quick info:
[MSK clinician performed]

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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16. 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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17. GP Advised Self-Management

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

GP information
If an unstable shoulder is diagnosed and there is no reason to consider immediate referral (see 'Wobbly Shoulder/Traumatic Dislocation' node), a 3 month self-management period can be considered. During this time, management may include:

  • analgesia as required
  • provision of the patient information leaflet
  • exercises (as demonstrated on the information leaflet)
  • consideration of referral to Tier 1 Physiotherapy

If symptoms persist beyond three months a referral to the MSK-MDT is indicated as per the pathway.

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18. 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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20. 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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21. 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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22. 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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23. 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.

Key Dates
Published: 18-Dec-2015, by Leeds
Valid until: 17-Feb-2017

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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

ID  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 2008; 110

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