Leeds Health Pathways

Shoulder and Elbow Pain

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

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

4 Olecranon Bursitis

Quick info:
GP information
The olecranon bursa:

lies over the ulna at the posterior tip of the elbow
since it is so near the surface, it is frequently subject to trauma typically caused by:
- constant irritation by leaning on the table whilst reading or writing hence often referred to as students elbow
- a fall on to a hard surface

The risk of acquiring this condition is increased in people:

who are subjected to repeated elbow trauma, eg labourers such as miners, gardeners, carpet layers and mechanics
with rheumatoid or crystalloid arthritis, eg gout
with a history of previous episodes of olecranon bursitis
with impaired immunity caused by steroids, diabetes, renal impairment, alcohol

History:

the principle symptoms are focal swelling overlying the posterior tip of the elbow, which may or may not be painless
clues about aetiology may be evident from the history
onset may date from an isolated episode of injury or occupation or activity may cause recurrent trauma

Examination:
A clearly demarcated swelling in the region of the posterior elbow tip is the classic finding:

it has been described as having the appearance of a 'goose egg'
the area may be tender to palpitation, with redness and warmth, particularly if infection is present
skin inspection may reveal contusion or abrasion if there was recent injury

Septic and non-septic bursitis cannot always be differentiated from the clinical features:

a painless, non-tender, simple swollen bursa that has been present for days to weeks is almost always due to non-septic causes
the following features may suggest a septic olecranon bursitis:
- hot, tender, painful and red swelling of the bursa
- systemic symptoms like fever and rigors
- immunocompromised state
- abrasion or laceration over the bursa
- seeking medical help early in the disease
erythema (in 63-100% of septic cases vs 25% of noninfective cases) is seen in both types

Clinical differentiation of acute gouty olecranon bursitis from septic olecranon bursitis is complicated since both present with red, hot, swollen and tender bursae with associated fever and raised white cell count.

Treatment:

not usually required for non-painful, small olecranon bursae
if there is significant pain or swelling however, aspiration is often necessary and the fluid should be sent for gram stain, culture and crystal microscopy
in case of non septic bursitis which can be identified clinically, the following conservative methods will be helpful:
- rest – immobilise the elbow until the swelling subsides
- application of ice
- use of an elbow pad – to minimise direct pressure on the swollen elbow
- compressive bandage
- elevation of the elbow
- analgesia
in cases refractory to above conservative methods, consider aspiration of fluid and injecting corticosteroids in to the bursa
in traumatic and inflammatory cases steroid injection may be helpful. In septic cases, adequate drainage should be achieved and appropriate antibiotics commenced

5 Epicondylitis Medial/Lateral

Quick info:
GP information
This pathway refers to the management of Tennis Elbow (Lateral Epicondylitis) and Golfer’s Elbow (Medial Epicondylitis). Lateral epicondylitis:

is strictly speaking a tendinopathy of the common extensor origin of the lateral elbow (particularly extensor carpi radialis brevis)
histologically despite the suffix ‘-itis’ is felt not to be inflammatory but rather a partially reversible degenerative tendinosis

Clinical features include:

tenderness at the lateral epicondyle
normal elbow range of motion (consider other diagnoses if range restricted)
elbow pain on resisted wrist extension, and middle finger extension

Medial epicondylitis:

describes a similar pathological process at the medial side of the elbow, affecting the flexor tendons and the tendons of pronator teres.

Clinical features include:

tenderness at the medial epicondyle
normal elbow range of motion
elbow pain on resisted wrist flexion and resisted forearm pronation

This condition may develop following activities involving repetitive use of the muscle groups of the forearm, including sporting, recreational and occupational activities.
An initial period of GP-advised self-management is appropriate (see node for details).
If symptoms persist, a referral to Tier 1 Physiotherapy is appropriate for the patient to receive advice on appropriate stretching and strengthening exercises (in line with other tendinopathies, eccentric exercises are used in the rehabilitation programmes).
If the patient fails to respond to Tier 1 physiotherapy then an onward referral will be made to the MSK-MDT. Similarly if the patient presents again soon after completing a course of physiotherapy, then a referral to the MSK-MDT would be appropriate. The MSK- MDT will re-assess and offer further management, including possible onward surgical referrals for recalcitrant cases.

6 Ulnar Nerve/Entrapment

Quick info:
GP information
Ulnar Nerve Entrapment:

the second most common upper limb entrapment neuropathy
location of entrapment is most frequently the elbow, though the wrist may also be implicated, and indeed entrapment can occur at different locations simultaneously

Elbow entrapment (also known as cubital tunnel syndrome):

may be secondary to various factors including:
- osteophytic pressure on the nerve in osteoarthritis
- dislocation or fracture of the elbow
- direct compression (habitual leaning on elbow)
- ganglia
- repetitive elbow flexion and extension (eg heavy manual work)
- tumours
- may also occur in association with medial epicondylitis

Entrapment of the ulnar nerve in the wrist:

occurs at Guyon’s canal between the pisiform and hamate
can be secondary to pressure of the hands against the handlebars in cyclists, and in those who work with vibrating drills

Symptoms may be sensory, motor or mixed. Sensory symptoms include tingling and numbness in the little finger and ulnar/medial half of the ring finger. Motor symptoms include grip weakness and weakness of finger abduction.
Signs include a ‘claw hand’ mainly affecting the little and ring finger, and wasting of the small muscles of the hand, with sensory loss of the little and medial ring finger. Special tests include Tinel’s sign when tapping over the cubital tunnel reproduces pain and sensory symptoms down the forearm to the hand. A positive elbow flexion test reproduces symptoms within 60 seconds with the elbow flexed beyond 90°, the forearm supinated and the wrist extended.
There may be mild or intermittent symptoms, and normal examination with a mild ulnar nerve entrapment. More severe lesions may present with constant pain, wasting of the small hand muscles and a claw deformity with loss of grip function and strength.
Mild cases of ulnar nerve entrapment can be managed in primary care (see pathway for further information).
It is appropriate to refer moderate and severe cases of ulnar nerve entrapment to the MSK-MDT for consideration of surgical decompression. It would also be appropriate to refer uncertain diagnoses to the MSK-MDT for further assessment and management.

7 Stiff and Painful Elbow

Quick info:
GP information
Causes of painful stiff elbow:

the commonest cause is injury/trauma
other causes include:
- primary osteoarthritis
- inflammatory arthritis
- joint infections (if suspected urgent hospital assessment is required)
- post fracture malunions

This pathway refers to those adults from middle-age who present with a stiff and painful elbow. An X-ray should be obtained to assess for elbow osteoarthritis.
Clinical features of elbow osteoarthritis include:

elbow pain
elbow stiffness / decreased range of motion
grating / locking / swelling
signs and symptoms of ulnar neuropathy secondary to osteophytic encroachment
history of elbow trauma (follow 'Stiff Elbow Post Injury' pathway if relatively recent injury)
occupation / hobby with repetitive stress to elbow joint

If the X-ray confirms osteoarthritis, then a referral to the MSK-MDT for further assessment +/- consideration of surgery is appropriate. If the X-ray shows no evidence of elbow then an alternative diagnosis should be sought and managed accordingly.

8 Stiff Elbow Post Injury >3 months

Quick info:
GP information
Causes of painful stiff elbow:

the commonest cause is injury/trauma
other causes include:
- primary osteoarthritis
- inflammatory arthritis
- joint infections (if suspected urgent hospital assessment is required)
- post fracture malunions

This pathway refers to those patients who present with a stiff elbow post injury. Factors that may predict increased stiffness include severity of the initial injury and length of elbow immobilisation following injury.
Since elbow stiffness is very common post-injury, a period of observation for three months is appropriate because usually this will improve. If stiffness persists after three months, a referral to Tier 1 physiotherapy is appropriate to assist and advice on exercises to regain a normal range of motion. If there is no improvement, Tier 1 physiotherapy will refer to MSK-MDT, who may refer onward to a surgeon.

9 Diagnosis Uncertain

Quick info:
GP information
If the symptoms are of new-onset, mild and without loss of range of movement and power at the elbow 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.

10 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.

12 GP Advised Self-Management

Quick info:
Patient information
See information leaflet on olecranon bursitis.

GP information
Detailed advice on the management of olecranon bursitis is described in the previous node. Self-management of mild non-septic olecranon bursitis can be summarised as follows:

rest of the affected elbow
application of ice
elbow pad to minimise direct pressure
compressive bandage
elevation of the elbow where possible
analgesia as required
provision of the attached information leaflet
advice to re-attend should symptoms persist or signs of infection develop

13 GP Advised Self-Management (+/- In House Steroid Injection)

Quick info:
Patient information
See information leaflet on tennis elbow. See patient information leaflet golfers elbow

GP information
The diagnosis of Lateral and Medial epicondylitis can usually be made confidently after clinical assessment (see previous node). GP-advised self-management may include:

limiting any identified provocative activity (sometimes this can be difficult when occupational activities are identified)
relative rest of the elbow
provision of analgesia
ice packs
use of a tennis elbow brace (correctly applied approximately 10cm below the elbow joint rather than on the painful part of the elbow) to unload the tendon
provision of the attached patient information leaflet
discussion with the patient regarding the exercises on the leaflet – once symptoms begin to settle (likely after cessation of any significant provoking activity and thus the acute tendon overload), stretching and strengthening / eccentric rehabilitation is appropriate
advice to the patient to attend for review if symptoms persist beyond 4-6 weeks for reassessment and consideration of referral to Tier 1 physiotherapy

A note about steroid injections:

steroid injections have been used to treat these conditions for a long time. Many GPs continue to inject tennis elbows and patients report successful outcomes. For this reason the MSK steering group felt it appropriate to include the option for GPs to continue this practice currently at their discretion.
it should also be noted however that a BMJ paper in 2011 by Orchard and Kountouris1 reviewed the evidence from randomised controlled trials concluding, ‘in most circumstances, cortisone injections should not be used. Cortisone leads to very good results in the short term (six weeks) but is harmful in the longer term (more than three months)’. They also note that short-
term outcome may be important for some patients with important activities in the forthcoming weeks, but for most, long-term
prognosis is most important.

¹ Orchard, J., Kountouris, A. The management of tennis elbow. BMJ 2011;342:d2687

14 Refer to Tier 1 Physiotherapy Referral Form (MSK11)

Quick info:
Referral Forms
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.

15 Severe OR Atypical

Quick info:
GP information
Where patients have typical signs and symptoms of ulnar nerve entrapment such that there is no doubting the diagnosis, and symptoms are severe, then an immediate referral to the MSK-MDT for further assessment and management is appropriate to facilitate timely access to surgical treatment.
Similarly an immediate referral to the MSK-MDT is indicated when the diagnosis is uncertain to ensure timely assessment and management.
Any weakness or wasting of the hand muscles should be considered as a strong reason to refer to the MSK-MDT.

16 Mild / Moderate

Quick info:
GP information
Mild to moderate ulnar nerve entrapment (intermittent symptoms, no loss of grip strength, normal examination) can be managed in primary care with a period of observation and appropriate advice provided to patients (see 'GP Explanation and Observation' node). If symptoms persist then a referral to the MSK-MDT would be indicated for further assessment and management.

19 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.

20 Referral to MSK-MDT Referral Form (MSK11)

Quick info:
Referral Forms
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.

21 GP Explanation and Observation

Quick info:
GP information
When a lesion is suspected at the elbow (most common), patients should be advised to:

avoid leaning / pressure on the elbows
avoid positions of prolonged elbow flexion

If compression is suspected in a cyclist at the Canal of Guyon in the wrist, simple advise includes:

using cycle gloves / handlebar padding
changing the hand position during cycling

All patients should be advised to return for review if symptoms persist or worsen. If patients develop persistent and/or painful symptoms, loss of grip strength, loss of muscle mass in the hand or clawing of the ring / little fingers then review and onward referral is indicated.

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

24 Refer to Tier 1 Physiotherapy Referral Form (MSK11)

Quick info:
Referral Forms
MSK11 Shoulder-Elbow Pain V3

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

25 Refer to MSK-MDT Referral Form (MSK11)

Quick info:
Referral Forms
MSK11 Shoulder-Elbow Pain V3

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

27 Referral to MSK-MDT Referral Form (MSK11)

Quick info:
Referral Forms
MSK11 Shoulder-Elbow Pain V3

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

28 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

33 Refer to MSK-MDT Referral Form (MSK11)

Quick info:
Referral Forms
MSK11 Shoulder-Elbow Pain V3

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

37 Refer to MSK-MDT Referral Form (MSK11)

Quick info:
Referral Forms
MSK11 Shoulder-Elbow Pain V3

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

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
Reference

American Academy of Orthopaedic Surgeons. AAOS clinical guideline on shoulder pain. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2001.
Australian Acute Musculoskeletal Guidelines Group. Acute Shoulder Pain. Canberra: National Health and
Medical Research Council; 2003.
Brigham and Women's Hospital. Upper extremity musculoskeletal disorders. A guide to prevention, diagnosis and treatment. Boston, MA: Brigham and Women's Hospital; 2006.
Clinical Knowledge Summaries (CKS). Shoulder pain. Newcastle upon Tyne: CKS; 2008.
Clinical Knowledge Summaries (CKS). Osteoarthritis. Newcastle upon Tyne: CKS; 2009.
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
Gotzsche P. Non-steroidal anti-inflammatory drugs. Clin Evid 2002; 1203-1211.
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
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
Speed C. Shoulder pain. Clin Evid 2008; 1107-31.