Previous changes

January to April 2017 — reviewed. A literature search was conducted in January 2016 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of the topic. Changes include:

• The differential diagnoses for shoulder pain has been revised.
• The diagnosis section, 'How do I assess someone with shoulder pain?', has been added. The clinical assessment of someone with shoulder pain has been revised. The Hawkins test has been taken out of the examination, as this is not recommended in the Oxford University hospitals guideline on the diagnosis of shoulder problems in primary care. 
• A section regarding the initial management of a person with shoulder pain has been added. The criteria for emergency and urgent referral to secondary care have been revised.
• The management sections for rotator cuff disorders, frozen shoulder, instability disorder, acromioclavicular joint disorders and glenohumeral osteoarthritis have been revised. 
• For the management of rotator cuff disorder, the following was added:
  • Do not give more than two corticosteroid injections. Normally only one injection should be given (due to the risk of tendon damage from repeated injections). A second injection may be given after 6 weeks, but only to people who have seen improvement following the first injection, and who need the pain relief to allow them to undergo physiotherapy.
• For the management of frozen shoulder,  the recommendation to refer to physiotherapy if a person can tolerate movement of the affected shoulder was removed. Many physiotherapists perform steroid injections, which can be performed in the pain predominant phase.  
• For the management of rotator cuff disorders, the recommendation not to give a corticosteroid injection if a rotator cuff tear is suspected was removed. Steroid injections are a management option for degenerative rotator cuff tears. Suspected traumatic rotator cuff tears should be referred urgently to orthopaedics.

April 2015 — minor update. Links have been inserted to the CKS topic on Analgesia - mild-to-moderate pain.

February 2013 — minor update. The 2013 QIPP options for local implementation have been added to this topic.

October 2012 — reviewed. A literature search was conducted in September 2012 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of the topic. A change has been to the recommendation on treatment of rotator cuff injury.

June 2011 — minor update. The 2010/2011 QIPP options for local implementation have been added to this topic. 

July 2010 — minor update. In people at risk of cardiovascular adverse events, ibuprofen up to 1200 mg per day or naproxen up to 1000 mg per day are recommended as first-line NSAIDs.

August to November 2008 — this is a new CKS topic. The evidence-base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence.

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 October 2022.

HTAs (Health Technology Assessments)

No new HTAs since 1 October 2022.

Economic appraisals

No new HTAs since 1 October 2022.

Systematic reviews and meta-analyses

No new systematic reviews published since 1 October 2022.

Primary evidence

No new primary evidence which reaches the CKS threshold for inclusion published since 1 October 2022.

New policies

No new national policies or guidelines since 1 October 2022.

New safety alerts

No new safety alerts since 1 October 2022.

Changes in product availability

No changes in product availability since 1 October 2022.

What are rotator cuff disorders?

• The term 'rotator cuff' refers to the group of muscles and tendons that surround and stabilise the shoulder joint [BMJ Best Practice, 2018].
• Rotator cuff disorders cause subacromial shoulder pain, which is felt in the top and lateral side of the shoulder [Kulkarni, 2015; Gray, 2016].
• Rotator cuff disorders include rotator cuff tendinopathy and partial rotator cuff tears [Mitchell et al, 2005; Kulkarni, 2015; Gray, 2016].
  
  • Rotator cuff tendinopathy is also known as shoulder impingement. Impingement occurs between the acromion and the rotator cuff tendons (which can be intact or torn). As the diagnosis of other causes of subacromial pain (such as supraspinatus tendinopathy, tendinitis, and subacromial bursitis) is essentially the same as rotator cuff tendinopathy, these are referred to as rotator cuff tendinopathy in this CKS topic [Kulkarni, 2015].
  • Rotator cuff tears can occur through either trauma (such as shoulder dislocation) or attrition (such as chronic degeneration), and can be either symptomatic or asymptomatic [BMJ Best Practice, 2018].
• Subacromial shoulder pain from rotator cuff disorders is the most common cause of shoulder pain presenting to primary care [Kulkarni, 2015; Gray, 2016].
  • It typically affects people between the ages of 35 and 75.
  • There may be a history of repetitive movements at or above shoulder height, or of heavy lifting.
  • It can occur in athletes, workers who perform overhead activities and the elderly [NZGG, 2004].
• Diagnosis is based on the history and examination [Kulkarni, 2015].
  • There is pain on the top and lateral side of the shoulder, which is made worse by raising the arm (for example when lifting a full kettle) or with overhead activities. There may be pain at night. On examination, active movements are painful and may be restricted, whereas passive movements tend to be full but painful [Mitchell et al, 2005; BMJ Best Practice, 2018].
  • There may be [Mitchell et al, 2005; Kulkarni, 2015]:
    • A painful arc of movement between 70-120 degrees of abduction (however research has not shown this to be sensitive or specific as a clinical sign).
    • Pain on abduction with the thumb down, which is worse against resistance.
• It is important to distinguish traumatic rotator cuff tear from other causes of subacromial shoulder pain.
  • Success of surgical repair is adversely affected by delayed diagnosis [Gray, 2016].
  • People with traumatic tears are usually active young to middle-aged adults and have usually sustained a dislocation or traction-type injury (where the shoulder is forcibly stretched).
  • On examination there is usually severe pain and significant weakness. There may be a positive 'drop arm test', where the person cannot support the weight of the affected arm when it is abducted to 90 degrees.
  • Urgent referral to orthopaedics is required [Kulkarni, 2015; Gray, 2016].

What is frozen shoulder?

• Frozen shoulder is a painful condition that leads to stiffness and disability [Rangan, A., 2015]. It is characterised by a progressive restriction of both active and passive shoulder movement [BMJ Best Practice, 2021], and typically affects people aged between 40-60 years [Gray, 2016]. 
• Frozen shoulder can be primary (idiopathic) or secondary [Rangan, A., 2015].
  • Secondary frozen shoulder is associated with trauma, rotator cuff disease, cardiovascular disease, hemiparesis, diabetes, and thyroid dysfunction [Rangan, A., 2015; BMJ Best Practice, 2021].
  • It has been estimated that the prevalence of frozen shoulder in people with diabetes is around 13 percent [Zreik, 2016].
  • Symptoms are often more severe and resistant to treatment compared to people without diabetes [Dias et al, 2005; Karbowiak, 2022].
  • Frozen shoulder is more common in women and in people who have previously had frozen shoulder in the opposite arm [Kelley, 2013]. 
• Frozen shoulder progresses through three overlapping phases [Rangan, A., 2015; Karbowiak, 2022]:
  • Painful phase (lasts 2-9 months). There is progressive pain on movement. The pain can become severe and disturb sleep.
  • Stiffness phase (lasts 4-12 months). The pain becomes less severe but is present at the end of the range of movement. Stiffness remains and there is reduction in the range of shoulder movements. Function can be substantially limited. 
  • Resolution phase (lasts 12-42 months). Gradual improvement in range of movement with less stiffness.
• As there is overlap between phases, frozen shoulder has been more recently classified into 'pain predominant' and 'stiffness predominant' phases [Hanchard, 2012; Rangan, A., 2015]. 
• Although symptoms usually settle in 18-24 months, there are reports of residual pain and stiffness persisting for several years in some people [BMJ Best Practice, 2021].
• The diagnosis of frozen shoulder is clinical [Kelley, 2013; Rangan, A., 2015; Rangan, 2016; BMJ Best Practice, 2021] and has the following features:
  • Gradual onset of pain in the deltoid region, with worsening shoulder stiffness, which may make activities of daily living difficult [Mitchell et al, 2005].
  • Restricted active and passive external rotation, and pain at the end of external rotation. There is a global limitation of active and passive range of shoulder movements with a capsular pattern (that is, a disproportionately severe reduction in passive external rotation).
  • Physical examination manoeuvres may be helpful to exclude other potential causes for a decreased range of motion in the shoulder (for example, rotator cuff disorders or cervical spine injury).
  • No obvious crepitus on movement.
  • X-rays are not routinely necessary. If performed, the glenohumeral joint should appear normal [Rangan, 2016]. 
  • It is important to note that restricted passive external rotation is seen in other disorders, such as glenohumeral osteoarthritis, avascular necrosis, and dislocation.

What are instability disorders?

• Shoulder instability is the abnormal movement of the head of the humerus. It can cause pain, subluxation (partial loss of contact between joint surfaces) or dislocation (the complete loss of contact between joint surfaces which needs a reduction manoeuvre) [Thangarajah, 2015]. 
• Dislocation can be acute, recurrent, or persistent (locked).
• Shoulder joint laxity is the asymptomatic movement of the humeral head on the glenoid cavity at the upper end of the normal range of movement.
• Laxity can occur without instability, and vice versa, or the two may co-exist [NZGG, 2004; Thangarajah, 2015].
• Shoulder instability has been classified as follows [Thangarajah, 2015; Gray, 2016; Brownson, 2015; Noorani, 2019]:
  • Traumatic structural instability. This is when the shoulder is dislocated by an external force. As the shoulder does not heal in the correct anatomical position, or structures do not heal properly, the person is more susceptible to recurrent dislocations and further damage. 96% of shoulder dislocations are due to trauma. 
  • Atraumatic structural instability. This is common in adolescent females with hypermobile joints. If the shoulder is lax, it becomes unstable spontaneously or following a minor injury. 
  • Muscle patterning. This is due to unbalanced muscle recruitment around the shoulder, and there is no structural abnormality. The person may have poor posture. 
  • These patterns can co-exist, or develop one after another with time. 
• Instability disorders usually occur in younger people, typically those aged less than 25 to 35 years of age [Brownson, 2015; Oxford Shoulder Clinic, 2010; Noorani, 2019].
• The person may give a history of the shoulder feeling that it moves partly or completely 'out of joint', and may be concerned their shoulder may dislocate during certain activities or sports. There may be other non-specific symptoms such as shoulder ache or intermittent clicking. If the instability is longstanding, there may be hand or arm weakness, tingling, or numbness from proximal nerve traction [Brun, 2012a]. Few tests of shoulder instability have been shown to be useful in practice [Thangarajah, 2015]. Often, there are no abnormalities on examination [Brun, 2012a]. The Beighton's score can be used if hypermobility is suspected [Thangarajah, 2015].
• Anterior dislocation is the most common traumatic dislocation and is most often seen in people aged 15-30. There is another peak in women aged over 80. Typically the person presents with significant pain following a fall onto an outstretched hand. On examination, there is loss of the normal contour of the shoulder [NZGG, 2004]. 
• A younger age at first dislocation is associated with a higher risk of repeated dislocation. A person aged less than 20 has a 90% chance of having a further dislocation [NZGG, 2004; Brownson, 2015]. Men are more likely than women to have a recurrence, and people with hyperlaxity are more likely to suffer dislocation than those without hyperlaxity [Olds, 2015].
• Injuries that may be associated with traumatic shoulder dislocations include nerve injury (for example, to the axillary nerve), greater tuberosity fracture and rotator cuff tear [Brownson, 2015; Noorani, 2019]. These injuries are more commonly seen in older people [Paxton, 2014].
• Posterior shoulder dislocation makes up 2-4% of all shoulder dislocations. The diagnosis is often missed at first presentation. This may be because the health care professional or the person with shoulder pain did not feel the injury was sufficient to dislocate the shoulder; because examination findings are more subtle than seen in anterior dislocation; or because only one X-ray view of the shoulder has been performed. Early diagnosis is important as there is often an associated fracture of the humeral head, which, if undetected, can lead to osteoarthritis or avascular necrosis [Jacobs, 2015]. Posterior dislocation can be caused by indirect trauma, with the arm flexed at the shoulder in adduction and internal rotation. It is important to consider posterior dislocation in someone with shoulder pain following a seizure. On examination, the person may hold the shoulder in adduction and internal rotation. There may be an abnormal shoulder contour. 
• Osteoarthritis is a complication of shoulder instability [Thangarajah, 2015]. 

What are acromioclavicular joint disorders?

These include acromioclavicular osteoarthritis and acromioclavicular joint injuries. 

• Acromioclavicular osteoarthritis is more common than osteoarthritis of the glenohumeral joint, but is often asymptomatic.
  • It usually presents in people over 60 [Gray, 2016]. The person may have previously sustained an acromioclavicular joint sprain.
  • Weightlifting (putting the joint under repetitive strain) is a risk factor [Brun, 2012a].
  • Symptoms include tenderness over the acromioclavicular joint, which is made worse by raising the arm up high or when the arm is brought across the body [Gray, 2016]. It may also be associated with rotator cuff disorders [Mitchell et al, 2005].
• Acromioclavicular joint injuries can involve stretching or tearing of the acromioclavicular or coracoclavicular ligaments and subluxation or dislocation of the acromioclavicular joint. They most commonly occur in men aged 20-50 years, and often result from a fall onto the point of the shoulder during sporting activity (for example, rugby and skiing) [NZGG, 2004].
• Acromioclavicular joint injuries are classified as [NZGG, 2004]:
  • Grade I: Intact joint with minor tear of the acromioclavicular ligaments.
  • Grade II: Up to 50% vertical subluxation of the clavicle with rupture of the acromioclavicular ligament and stretching of the coracoclavicular ligaments. 
  • Grade III: more than 50% vertical subluxation of the clavicle with complete rupture of both acromioclavicular and coracoclavicular ligaments. 
• On examination there may be tenderness localised to the AC joint, limited range of movement due to pain, high arc pain, or a positive cross arm test  [NZGG, 2004; Oxford Shoulder Clinic, 2010; Brun, 2012a].
• There may be asymmetry of the shoulder contours following AC joint injury, however, this may only become apparent weeks after an injury [NZGG, 2004]. 

What is glenohumeral joint osteoarthritis?

• Glenohumeral joint osteoarthritis is a less common cause of chronic shoulder pain, but can cause significant pain and disability [Thomas, M., 2016]. As the shoulder is a non-weight-bearing joint, primary arthritis is rare. Secondary causes account for the majority of cases, such as following trauma, chronic rotator cuff tear, and systemic arthritis [Goud, 2008]. 
• Glenohumeral joint osteoarthritis is more common in people older than 60 [Mitchell et al, 2005].
• It presents with deep joint pain and restriction of activities, such as putting on a jacket [Mitchell et al, 2005; Gray, 2016]. Other joints may be involved [Thomas, M., 2016].
• On examination there is a global restriction in active and passive shoulder movement, with a severe loss of passive external rotation [Mitchell et al, 2005; Thomas, M., 2016].
• X-rays of the shoulder (AP and axillary views) are needed to confirm the diagnosis [Thomas, M., 2016]. 

Basis for recommendation

• The recommendations on how to assess a person with shoulder pain are based on UK guidelines from the British Elbow and Shoulder Society (BESS) and British Orthopaedic Association (BOA), which recommend the use of the Oxford University Hospitals guideline for the diagnosis of common shoulder problems in primary care 
  [Oxford Shoulder Clinic, 2010; Kulkarni, 2015; Brownson, 2015; Rangan, A., 2015; Thomas, M., 2016; Noorani, 2019]. Recommendations are also based on a New Zealand guideline on the diagnosis and management of soft tissue shoulder injuries and related disorders [NZGG, 2004], reviews of the management of shoulder pain in primary care [Mitchell et al, 2005; Artus, 2014], a review of the initial assessment of the injured shoulder [Brun, 2012b], a review of the management of the unstable shoulder [Thangarajah, 2015], and a textbook of clinical examination [Macleod's Clinical Examination, 2018]. 
• Recommendations on assessment and diagnosis are also closely aligned with the core values and behaviours described in the NHS England musculoskeletal core capabilities framework for first point of contact practitioners [NHS Health Education England, 2018].

General approach to management

• CKS advises a general approach to assessment and has not included a large number of specific tests (e.g. for individual muscles, tendons, or joints) because:
  • There is no evidence that any specific test is both valid and reliable for the diagnosis of shoulder injuries [NZGG, 2004].
  • A Cochrane review concluded there was no sufficient evidence for which tests should be used to identify shoulder impingement in primary care, and that tests to diagnose acromioclavicular joint disease are of limited value. There is no evidence that a reduced range of passive external rotation is accurate in diagnosing frozen shoulder [Hanchard, 2011].  
  • A review concluded that no single test in the shoulder examination can be reliably recommended to make a diagnosis [Hegedus, 2012].
  • There is a lack of consensus on diagnostic criteria and clinical assessment, even between musculoskeletal specialists. Additionally, mixed shoulder disorders are common and over-differentiation between the many diagnostic categories is unlikely to alter standard primary care management [Mitchell et al, 2005].

Investigations in primary care

• CKS does not recommend routine investigations in primary care:
  • Review articles [Mitchell et al, 2005; Artus, 2014] advise that malignancy and systemic illnesses are infrequent causes of shoulder pain, and that blood tests, such as full blood count and erythrocyte sedimentation rate should be performed if there are red flag symptoms or examination findings. 
  • Due to the high prevalence of frozen shoulder in people with diabetes, and the high prevalence of diabetes in people with frozen shoulder, the authors of a meta-analysis advised that diabetes should be considered in people presenting with frozen shoulder [Zreik, 2016]. 
• The recommendations regarding when to consider performing X-rays are based on a review article [Artus, 2014] and the BESS/BOA guideline [Kulkarni, 2015].
  • The diagnosis of frozen shoulder is essentially clinical. X-rays are not routinely needed unless to exclude arthritis [NZGG, 2004; Rangan, 2016]. The BESS/BOA guideline recommends performing an X-ray to confirm the diagnosis of glenohumeral osteoarthritis and exclude other diagnoses such as avascular necrosis [Rangan, A., 2015]. 
  • The BESS/BOA guideline for the management of subacromial shoulder pain advises considering an X-ray if the person is not improving with conservative treatment [Kulkarni, 2015]. 
  • The BESS/BOA guideline recommends that diagnostic ultrasound is performed in secondary care, rather than in primary care [Kulkarni, 2015]. A normal ultrasound of the rotator cuff does not exclude serious causes of shoulder pain, such as malignancy. The accuracy of ultrasound in diagnosis is dependent on the clinician performing the examination. Partial tears are a common report finding; however, these can be asymptomatic or a false positive examination finding. Therefore if a tear is found on ultrasound, it does not always correlate with the person's symptoms or mean surgery will definitely be needed. The BESS/BOA guideline recommends ultrasound findings should be interpreted by orthopaedic surgeons and considered along with the person's symptoms and previous management. A review also recommends that ultrasound and MRI scans are usually secondary care investigations [Artus, 2014]. 

How should I manage a person with shoulder pain initially?

• Refer a person urgently to secondary care if any red flags are identified in the history or examination. These include: 
  • Trauma, pain and weakness, or sudden loss of ability to actively raise the arm (with or without trauma): suspect acute rotator cuff tear.
  • Any shoulder mass or swelling: suspect malignancy.
  • Red skin, painful joint, fever, or the person is systemically unwell: suspect septic arthritis.
  • Trauma leading to loss of rotation and abnormal shape: possible shoulder dislocation.
  • New symptoms of inflammation in several joints: suspect inflammatory arthritis. 
• Also consider urgent investigations and/or referral to secondary care if there: 
  • Are systemic symptoms such as fever, night sweats, weight loss, or new respiratory symptoms. 
  • Is undiagnosed severe shoulder pain or severe restriction of movement.  
  • Is a history of trauma and the person is being seen acutely.
• Refer a person urgently to secondary care for same-day emergency assessment for: 
  • Suspected joint infection (red skin, person has fever or is systemically unwell).
  • Unreduced dislocation (trauma, epileptic fit, or electric shock leading to abnormal shoulder shape and loss of rotation).
  • Acute trauma, depending on clinical judgement.
• Refer a person urgently for suspected:
  • Malignancy (past history of cancer, symptoms or signs of cancer, mass or swelling, unexplained deformity, lymphadenopathy). Follow the local 2-week referral pathway.
  • Acute rotator cuff tear caused by trauma (trauma, pain, and weakness). Refer urgently to orthopaedics. The person should be seen in the next available specialist shoulder clinic. 
  • Inflammatory arthritis. Follow the local rheumatology referral pathway.
  • Neurological lesion (unexplained wasting, significant motor or sensory deficit). Discuss with neurology, neurosurgery or orthopaedics, depending on clinical judgement. 
• For suspected intrinsic shoulder disorders, follow the Oxford University Hospitals guidelines for the diagnosis, treatment and referral of common shoulder problems in primary care www.ouh.nhs.uk [Oxford Shoulder Clinic, 2010].
  • If there is a history of instability (the shoulder has ever come out of joint, or the person is concerned their shoulder may dislocate during certain activities or sport) a diagnosis of instability is likely.
  • If there is pain and tenderness over the AC joint, high arc pain, or a positive cross-arm test, acromioclavicular joint disease is likely.
  • If there is reduced passive external rotation, a diagnosis of a glenohumeral joint disorder (frozen shoulder or arthritis) is likely. 
  • If there is a painful arc of abduction or pain on abduction with the thumb down, a diagnosis of a rotator cuff disorder is likely.  Note that a young person with a history of trauma and a loss of abduction needs urgent referral to exclude acute cuff tear. 
• For the initial management of a person with shoulder pain without any red flags:
  • Explain the diagnosis to the person and offer an information leaflet, such as the Versus Arthritis Shoulder Pain leaflet.
  • Prescribe appropriate analgesia. Offer paracetamol first line. If paracetamol is ineffective, consider an oral NSAID (for example, ibuprofen) or codeine. Consider whether there are any contraindications and which drug has a more favourable balance of benefits and risks for the person. If there is no early benefit from an oral NSAID, discontinue its use. For prescribing information on NSAIDs, information on minimizing associated risks and when to consider gastroprotection, see the CKS topic on NSAIDs - prescribing issues. For prescribing information on codeine, see the CKS topic on Analgesia - mild-to-moderate pain.
  • Consider the person's work and leisure activities. 
  • Advise the person to carry out normal activities as much as they are able to. Consider a short time off work, for example, one week, if there appears to be a direct link between this and the shoulder pain. Advise rest from activities that worsen the shoulder pain for a few weeks, such as sport, and, if relevant, advise 'light duties' at work for a few weeks. 
  • Explain that although common shoulder problems tend to be self-limiting, the rehabilitation period can be at least 6 months.
• Consider reviewing the person after 2 weeks of initial management:
  • If symptoms are severe, arrange an earlier review. Advise the person to reattend sooner if symptoms worsen. 
  • Consider referral to physiotherapy.
  • Adopt shared decision making.
  • See the relevant sections for the management of Rotator cuff disorders, Frozen shoulder, Instability disorders, Acromioclavicular joint disorders, and Glenohumeral osteoarthritis.
• Refer early to secondary care if:
  • There is recurrent shoulder instability.
  • There is severe post-traumatic pain.
  • The pain is having a significant impact on the person, for example, on work or if they are an athlete.
• Refer to secondary care if pain and function are not improving following conservative treatment for 3 months.
• Consider referral to a specialised musculoskeletal clinic, for example, for provision of physiotherapy or corticosteroid injection. However, if orthopaedic referral is indicated, do not delay this referral.

How should I manage a person with frozen shoulder?

• Explain the diagnosis and what the person should expect. 
  • Pain is the main problem initially. It can be worse in bed and disturb sleep. 
  • The pain gradually improves, but stiffness slowly worsens and becomes the main problem. The stiffness then gradually resolves.
  • Frozen shoulder is usually self-limiting, but it can take months to years to resolve. 
• Advise on activity modification and pain control. 
  • When the shoulder is painful, continue to use the arm to maintain movement and ease spasm. Avoid movements which worsen the pain. This may require time off work or away from leisure activities.
  • Take analgesia as advised.
  • Hot packs may be helpful. 
  • In bed, support the arm with pillows (to prevent rolling onto the affected shoulder).
• Consider the following in the person's management:
  • Analgesia.
  • Supervised physiotherapy/domestic exercise programme.
  • Intra-articular corticosteroid injection.
  • Referral to secondary care.
• Consider following a step-up approach, starting with non-invasive treatments, and moving on to invasive ones, if required.
  • Consider the severity of symptoms and the impact it is having on the person (how much this is restricting work or leisure activities) when planning treatment.  
• Offer analgesia, particularly in the early, painful phase.
  • Consider paracetamol first line. Regular dosing is more effective than 'as required use'. For further information see the CKS topic Analgesia - mild-to-moderate pain. 
  • If paracetamol is ineffective, consider an oral NSAID (for example, ibuprofen) or codeine. Consider any contraindications and which drug has a more favourable balance of benefits and risks for the person. 
  • If there is no early benefit from an oral NSAID, discontinue its use. 
  • For prescribing information on NSAIDs, information on minimizing associated risks, and when to consider gastroprotection, see the CKS topic on NSAIDs - prescribing issues.
  • For prescribing information on codeine, see the CKS topic on Analgesia - mild-to-moderate pain.
• Consider referral for physiotherapy. Start physiotherapy as early as possible in the course of frozen shoulder. Ensure adequate analgesia is provided.
  • The course of physiotherapy is usually 6 weeks unless the person cannot tolerate the exercises or the physiotherapist advises earlier referral to secondary care.
  • Physiotherapy can be continued for a further 6 weeks if there is improvement in the person's symptoms or function.
  • Physiotherapy can involve education and advice, exercises, manual therapy, thermotherapy, and electrotherapy. A corticosteroid injection or acupuncture may be performed by the physiotherapist.  
• Consider an intra-articular (glenohumeral) corticosteroid injection early in the course of frozen shoulder if there is no, or slow, progress with conservative treatment. 
  • This can be done in primary care if the expertise is available, otherwise refer to orthopaedics, physiotherapy, or intermediate care. 
  • Intra-articular corticosteroid injections should be administered by an appropriately trained and skilled person.
  • Discuss potential adverse effects when obtaining informed consent. These include infection (rare if sterile technique is used), tendon rupture, 'post-injection flare of pain', and hyperglycaemia in people with diabetes.
  • Although a number of steroid preparations are available, triamcinolone or methylprednisolone are the preferred option for many specialists.
  • Local anaesthetic (e.g. lidocaine) is frequently used in addition to corticosteroid. Advise the person to rest the injected joint as much as is practical for 24 hours following the injection. Advise them that if there is severe pain after the injection, especially if it is associated with fever or shivering, to seek urgent medical advice.
  • Vigilant self-monitoring of blood sugars is recommended for people with diabetes following steroid injection, as transient hyperglycaemia may occur for 24–48 hours.
  • Where feasible, steroid injections should be deferred until diabetes is well-controlled and the risk of infection should be carefully considered.
  • If a corticosteroid injection does not produce the expected benefit, the diagnosis should be reviewed or referral considered.
• Do not give a corticosteroid injection if:
  • The person has previously had an intra-articular corticosteroid injection from an experienced healthcare practitioner, with minimal or no benefit.
  • The pain has settled and stiffness is the predominant feature.
  • Corticosteroid injection is contraindicated (e.g. infection, sensitivity to local anaesthetic, or adjacent osteomyelitis).
• Refer to secondary care:
  • If the person has had pain and or stiffness for up to 3 months and has not benefited from conservative measures. Consider referral earlier than this if symptoms are severe, or there is considerable impact on the person's quality of life.
  • If there is uncertainty about the diagnosis.
  • For consideration of a corticosteroid injection, if this cannot be done in primary care.

How should I manage a person with a rotator cuff disorder?

• Consider the following in the person's management:
  • Rest (in the acute phase).
  • Exercise/ physiotherapy.
  • Corticosteroid injection.
  • Referral to intermediate or secondary care.
• Adopt a shared-decision making approach when making management plans, and consider making treatment goals. 
• Advise rest in the acute phase. Following this, activity should gradually be increased. 
• Advise modification of activities that exacerbate symptoms (such as reaching overhead). Usual activities, within the limits of pain, should be restarted as soon as possible.
• Offer analgesia.
  • Consider paracetamol first line. Regular dosing is more effective than 'as required use'. For further information see the CKS topic on Analgesia - mild-to-moderate pain
  • If paracetamol is ineffective, consider an oral NSAID (for example, ibuprofen) or codeine. Consider any contraindications and which drug has a more favourable balance of benefits and risks for the person. 
  • If there is no early benefit from an oral NSAID, discontinue its use. 
  • For prescribing information on NSAIDs, information on minimising associated risks and when to consider gastroprotection, see the CKS topic on NSAIDs - prescribing issues.
  • For prescribing information on codeine, see the CKS topic on Analgesia.
• Refer for physiotherapy.
  • The course of physiotherapy is usually 6 weeks, unless the person cannot tolerate the exercises or the physiotherapist advises earlier referral to secondary care.
  • Physiotherapy may include postural correction, motor control retraining, stretching and strengthening of the rotator cuff and scapular muscles, and manual therapy.
  • Low intensity and high-frequency exercise, that is within the person's pain threshold, should be performed.
  • Physiotherapy can be continued for a further 6 weeks if there is improvement in the person's symptoms or function.
• Consider a subacromial corticosteroid injection as part of shared decision making, and in conjunction with other primary care treatments, such as physiotherapy.
  • This can be done in primary care if the expertise is available, otherwise refer to orthopaedics, physiotherapy, or intermediate care. 
  • Intra-articular corticosteroid injections should be administered by an appropriately trained and skilled person.
  • Discuss potential adverse effects when obtaining informed consent. These include infection (rare if sterile technique used), tendon rupture, 'post-injection flare of pain', and hyperglycaemia in people with diabetes
  • Although a number of steroid preparations are available, triamcinolone or methylprednisolone are the preferred option for many specialists.
  • Local anaesthetic (e.g. lidocaine) is frequently used in addition to corticosteroid.
  • Advise the person to rest the injected joint as much as is practical for 24 hours following the injection. Advise the person that if there is severe pain after the injection, especially if associated with fever or shivering, to seek urgent medical advice. 
  • Vigilant self-monitoring of blood sugars is recommended for people with diabetes following steroid injection, as transient hyperglycaemia may occur for 24–48 hours.
  • Where feasible, steroid injections should be deferred until diabetes is well-controlled and the risk of infection should be carefully considered.
  • If a corticosteroid injection does not produce the expected benefit, review the diagnosis or consider referral.
• Do not give more than two corticosteroid injections. 
  • Normally only one injection should be given (due to the risk of tendon damage from repeated injections).
  • A second injection may be given after 6 weeks, but only to people who have seen improvement following the first injection, and who need the pain relief to allow them to undergo physiotherapy. 
• Do not give a corticosteroid injection if:
  • The person has previously received a corticosteroid injection from an experienced healthcare practitioner, with minimal or no benefit.
  • The person has previously had two injections in the same shoulder.
  • Corticosteroid injection is contraindicated (e.g. infection, sensitivity to local anaesthetic, adjacent osteomyelitis).
• Consider referral to intermediate care, if appropriate and locally available:
  • Integrated Clinical Assessment and Treatment Services (ICATS) can offer: assessment, treatment programmes (non-surgical), and referral to secondary care.  
• Refer to secondary care if:
  • The person has not benefited from at least 6 weeks of non-surgical treatment (for example has persistent pain and reduced function).
  • The diagnosis is uncertain.
• Consider factors that could delay surgical treatment if referring to secondary care. For example, investigate and treat diabetes.
• Refer urgently to secondary care:
  • If any red flag features are present, see Initial management. 
  • If acute rotator cuff tear caused by trauma is suspected (trauma, pain, and weakness). Ideally, the person should be seen in the next available specialist shoulder clinic. 

How should I manage a person with an instability disorder?

• Refer immediately to an Emergency Department if acute dislocation is suspected. The person, or any bystanders, should not try to reduce the dislocation. There may be associated injuries; therefore, clinical assessment and radiological investigations should be performed, and reduction performed in a controlled environment. 
• Following initial assessment and reduction of an acute traumatic shoulder dislocation: 
  • Encourage early mobilisation (as soon as the pain allows). 
  • Refer to physiotherapy. The course of physiotherapy is usually 4-12 weeks. 
  • Note that most people with an acute dislocation will have follow up in secondary care.
    • People aged under 25 should be seen by a shoulder surgeon within 6 weeks to consider whether surgical repair is appropriate.
    • People aged 25-40 should be assessed for symptoms of shoulder instability at 3-6 months, and further imaging and surgery considered if there are still symptoms.
    • People aged over 40 should have early imaging following a dislocation to check the integrity of the rotator cuff. If a rotator cuff tear is found, the person should be reviewed by a shoulder surgeon regarding the need for surgery.
• Refer urgently to orthopaedics if a rotator cuff tear is suspected in a person who has recently sustained an acute shoulder dislocation. Suspect a rotator cuff tear if there is still pain and weakness 2-3 weeks following dislocation.
• Refer to a shoulder surgeon:
  • Following first-time dislocation.
  • If the person has had recurrent painful dislocations.
  • If symptoms are impacting on the person's job or leisure activities. 
  • If the person has had a shoulder dislocation associated with an epileptic seizure.
  • If symptoms following shoulder dislocation are not improving with physiotherapy.
  • If there are associated injuries, such as fracture.
• Refer to physiotherapy if:
  • Atraumatic shoulder instability is suspected. Refer to orthopaedics if physiotherapy is not beneficial. 
  • Muscle patterning instability is suspected. Refer to orthopaedics if the shoulder is still unstable despite physiotherapy.
• Refer urgently if any red flag features are present.

How should I manage a person with an acromioclavicular joint disorder?

• For osteoarthritis of the acromioclavicular joint:
  • Advise the person on activity modification, in particular, to avoid cross-body shoulder adduction (for example, playing golf), and to avoid heavy lifting.
  • Offer analgesia.
  • Consider referral to physiotherapy.
  • Consider corticosteroid injection if pain is severe.
  • Arrange an X-ray (if this has not already been done) and refer to orthopaedics if there is no, or only temporary, improvement following the above measures.
  • See the CKS topic on Osteoarthritis for further information regarding the management of osteoarthritis.
• Analgesia
  • Consider paracetamol first line. Regular dosing is more effective than 'as required' use. For further information, see paracetamol prescribing issues in the CKS topic Analgesia - mild-to-moderate pain.
  • If paracetamol is ineffective, consider an oral NSAID (for example, ibuprofen) or codeine. Consider any contraindications and which drug has a more favourable balance of benefits and risks for the person.
  • If there is no early benefit from an oral NSAID, discontinue its use.
  • For prescribing information on NSAIDs, information on minimising associated risks and when to consider gastroprotection, see the CKS topic on NSAIDs - prescribing issues.
  • For prescribing information on codeine, see the CKS topic on Analgesia.
• For acromioclavicular joint injuries
  • Refer for an X-ray or to accident and emergency, depending on clinical judgement, if there is a history of trauma see Initial management.
  • If the acromioclavicular joint pain is caused by a mild sprain following an acute injury (See grade I or II sprains):
    • Initially, advise rest, consider providing a sling for 5–7 days, and offer analgesia (see analgesia section above).
    • Start gentle mobilisation and strengthening when the person is more comfortable. Consider referral to physiotherapy.
    • Advise the person to resume normal activities as tolerated, but avoid heavy lifting and contact sports for 8–12 weeks.
    • Refer to orthopaedics if symptoms are not settling following conservative management. Consider earlier referral for certain groups for whom shoulder pain is particularly disabling (for example, athletes involved in overhead sports or people involved in heavy manual labour).
  • For more severe injuries (grade 3 or higher dislocations), or if there is diagnostic uncertainty, discuss with, or refer to, orthopaedics.

How should I manage a person with glenohumeral joint osteoarthritis?

• For information on the management of osteoarthritis, see the CKS topic on Osteoarthritis.
• Management decisions should be based on the severity of symptoms and the impact on the person's function, quality of life, mood, occupation, and leisure activities.
• Consider the following core treatments for everyone with osteoarthritis:
  • Education and advice Information and advice.
  • Strengthening exercises. Consider referral to physiotherapy.
  • Weight loss if the person is overweight.
  • Assistive devices for people who have specific problems with activities of daily living. Consider seeking expert advice from an occupational therapist or Disability Equipment Assessment Centre.
• Consider the following for a person with glenohumeral osteoarthritis:
  • Analgesia.
  • Physical therapy. Consider referral to physiotherapy.
  • Corticosteroid injection.
• Offer analgesia.
  • Consider paracetamol first line. Regular dosing is more effective than 'as required' use. For further information, see paracetamol prescribing issues in the CKS topic on Osteoarthritis.
  • If paracetamol is ineffective, consider a topical NSAID. For further information, see the Topical NSAID prescribing information in the CKS topic on Osteoarthritis - Topical NSAIDs.
  • If topical medicines are ineffective or unsuitable, consider an oral NSAID (for example, ibuprofen) or codeine. Consider any contraindications and which drug has a more favourable balance of benefits and risks for the person.
  • If there is no early benefit from an oral NSAID, discontinue its use.
  • For prescribing information on NSAIDs, information on minimising associated risks, and when to consider gastroprotection, see the CKS topic on NSAIDs - prescribing issues.
  • For prescribing information on codeine, see the CKS topic on Analgesia - mild-to-moderate pain.
• Consider a corticosteroid injection for the short-term management of an acute exacerbation of pain due to joint inflammation, or for temporary symptom control, for example, if surgery has been delayed. For further information, see Intra-articular corticosteroids prescribing information in the CKS topic on Osteoarthritis.
• Refer to secondary care if:
  • Conservative measures do not control pain.
  • Stiffness is having a significant impact on the person.
  • The diagnosis is uncertain.
• If a referral is needed for consideration of surgery, check that the person wishes to be referred.
• Refer before there is prolonged and established functional limitation or severe pain.