Stiff shoulder- Adult Leeds
1. 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
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
4. Frozen
Quick info:
Patient information
See patient information leaflet on frozen shoulder.
GP information
A frozen shoulder, or adhesive capsulitis is a condition characterised by pain, stiffness and reduced range of movement of the shoulder. It may follow prolonged immobilisation or trauma, but is commonly idiopathic.
Idiopathic frozen shoulder generally occurs:
- between age 40-60 years
- more commonly in females
- in the non-dominant arm (thus most commonly the left shoulder)
- in those with diabetes (it is worth checking a fasting glucose in those with this condition)
On examination active and passive range of movement is reduced, though the most useful finding is range of external rotation relative to the other shoulder. This is best assessed by asking the patient to hold their elbows to their side, flex the elbow to 90° and bring the forearm away as far as possible from the body. A clear discrepancy between the affected and unaffected shoulder is suggestive of a frozen shoulder.
Frozen shoulder has 3 phases:
- Phase 1 (2-9 months) – ‘freezing’ / painful. Pain typically worse at night lying on the affected side precedes stiffness and movement restriction.
- Phase 2 (4-12 months) – ‘frozen’ / stiff. Pain may ease but stiffness persists in all movements of the shoulder, with external rotation most severely affected.
- Phase 3 (5 months – 4 years) – ‘thawing’ / recovery. Pain / stiffness gradually recovers with concurrent improvement in range of movement to normal / near normal range.
The typical untreated duration of the condition is 2-3 years. Management of the condition should include:
- Discussion of the natural history of the condition and establishing whereabouts the patient lies within it. The patient may opt to wait and see.
- Consider fasting glucose.
- Those who present within 3 months of onset of symptoms may benefit from a steroid injection. These patients should be offered GP unguided steroid injection if local expertise exists, or referral to MSK-MDT for unguided injection if unable to provide in- house. If symptoms continue to persist after unguided injection, referral to MSK-MDT for consideration of other management options including guided injection and consideration for surgery is appropriate.
- Those who present later than 3 months from onset of symptoms are very unlikely to benefit from steroid injection and self- management advice (see node) should be provided and provision made to review at 4 weeks. If symptoms persist, the patient may benefit from referral to Tier 1 Physiotherapy. If deemed necessary for persistent or severe symptoms an onward referral to the MSK-MDT can be considered for further assessment and treatment.
5. Suspected Osteoarthritis (usually age >65 years)
Quick info:
GP information
Osteoarthritis of the shoulder should be suspected in patients who present with a painful and stiff shoulder aged 65 years and above. Typical signs and symptoms include:
- painful stiff shoulder worse with use
- sleep disturbance due to pain
- ‘grating’ / ‘catching’ during movement
- limited range of movement on clinical examination
In the presence of these findings an X-Ray of the affected shoulder should be obtained. If osteoarthritis is not confirmed, the patient should be managed according to the 'Frozen shoulder' pathway if this diagnosis is now likely, or according to any other pathology revealed.
If OA shoulder is confirmed, an assessment of the severity of the condition should be ascertained:
- mild/moderate symptoms (minimal pain / little requirement for analgesia / reasonable range of movement and no disruption of activities of daily living):
- can be managed with as required analgesia and provision of self management advice
- if symptoms persist, referral to Tier 1 Physiotherapy is indicated
- if symptoms persist despite Tier 1 Physiotherapy, referral to MSK-MDT to consider surgical opinion (see referral guidance for further information)may be warranted
- severe symptoms (significant pain requiring frequent use of analgesia / significantly reduced range of movement and disruption of activities of daily living):
- referral to MSK-MDT to consider surgical opinion (see referral guidance for further information)may be warranted
9. GP Advised Self-Management
Quick info:
Patient information
See patient information leaflet on frozen shoulder.
GP information
For those individuals who present later than three months from onset of symptoms of a frozen shoulder it is reasonable to consider a 4 week trial of self-management. Steroid injection is very unlikely to benefit this group. Self management would include:
- analgesia as required
- provision of the patient information leaflet
- exercises (as demonstrated on the information leaflet)
If at 4-week review the symptoms persist then the patient may benefit from referral to Tier 1 Physiotherapy. If deemed necessary for persistent or severe symptoms an onward referral to the MSK-MDT can be considered for further assessment and treatment.
13. 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.
18. Severe Symptoms - Willing and Able to have Surgery
Quick info:
GP information
Shoulder replacement surgery may be indicated for a select few patients who have severe unrelenting pain and loss of function, and conservative treatment has failed.
Different procedures exist including:
- Partial (shoulder hemi-arthroplasty) – one articular surface is replaced (the humeral head)
- Total (shoulder arthroplasty) – both articular surfaces are replaced
- Reverse – both articular surfaces replaced; however, the socket is switched to the humeral side, with the ball at the glenoid.
Before referral, the following factors should be discussed with the patient:
- Does the patient wish to consider surgery? The following points may be helpful in making a decision.
- Is the patient fit for surgery? Are there significant co-morbidities?
- Surgical treatment outcomes should include pain reduction and improved movement. Shoulder movement may remain restricted however, and though generally the arm can be raised to a position where the elbow is level with the shoulder, movement would not be above this.
- Engagement with post-operative rehabilitation is essential, and should begin with gentle range of movement exercises very soon after surgery.
- There is a prolonged recovery period. A sling is likely to be advised at night for one month, and the arm cannot be used to push up. No significant lifting should be attempted for six weeks after surgery, and no heavy lifting for at least six months.
- Surgical complications include anaesthetic risks, wound infection, thromboembolic events, nerve/blood vessel damage, post- operative upper humeral fractures and shoulder instability, and glenoid component loosening/ failure.
- The best results tend to be in elderly patients who have had surgery for OA who tend to place less strain on the joint.
19. GP Advised Self-Management
Quick info:
GP information
For those patients diagnosed with mild or moderate shoulder osteoarthritis, GP advised self-management would include:
- provision of analgesia
- consideration of Referral to Tier 1 Physiotherapy
If symptoms persist and have become severe then it would be appropriate to consider referral to MSK-MDT to consider surgery if the patient is willing and able (see 'Severe Symptoms - Willing and Able to have Surgery' node for guidance).
20. 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.
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.
22. 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.
23. 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.
Key Dates
Published: 18-Dec-2015, 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
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; 1107-31.