Evidence Based Shoulder Pain Diagnosis

A lovely pretty flow chart from Noorani et. al made less pretty into words

Shoulder pain can be frustrating and confusing. Below is a simplified version of a clinical flowchart that outlines how to differentiate common shoulder problems and determine the best course of treatment or referral.

1. First Things First: Is It the Neck or the Shoulder?

Before diving into a shoulder-specific diagnosis, it’s important to determine whether the pain originates in the neck or in the shoulder itself. Ask the patient to:

• Move the neck first.
• Move the shoulder next.

Compare which movement reproduces the pain. If the pain is worse with neck movements, the issue may be cervical in origin. If the shoulder movement triggers the pain, the focus shifts to the shoulder.

2. Assessing Shoulder Instability

Instability is more common in younger patients (typically aged 10–35 years). Key questions include:

• Does the shoulder ever partly or completely “come out” of joint?
• Is there concern about the shoulder dislocating during activities or sports?

Management Tips:

• Atraumatic Instability: Often managed with physiotherapy. If the instability is not accompanied by trauma, a structured exercise program is usually the first step.
• Traumatic or Persistent Instability: If there’s a clear traumatic history, ongoing symptoms, or if conservative physiotherapy fails, a referral to a specialist is advised.

3. Acromioclavicular (AC) Joint Disease

Ask if the pain is specifically localized to the AC joint and if there’s tenderness on palpation. Additionally, note if there’s pain during activities that require high arc movements (when raising the arm).

Management Options:

• Conservative Treatment: Rest, NSAIDs/analgesics, steroid injections, and physiotherapy.
• Referral: If there is no significant improvement with initial treatment, consider referring the patient for further assessment.

4. Glenohumeral Joint Issues: Frozen Shoulder and Arthritis

When the shoulder has reduced passive external rotation (difficulty moving the arm even when the patient relaxes), the problem may lie within the glenohumeral joint:

• Frozen Shoulder: Common in patients aged 35–65 years. The shoulder may feel stiff and painful even with minimal movement.
• Arthritis: More likely in patients over 60 years. An X-ray can help differentiate between a frozen shoulder and arthritis.

Treatment Options:

• Frozen Shoulder: Often managed with physiotherapy and anti-inflammatory measures. If atypical or severe, consider early referral.
• Arthritis: Conservative management with pain relief strategies is typical, with referral for persistent or advanced cases.

5. Rotator Cuff Tendinopathy

A painful arc of abduction—especially when the pain worsens with the thumb-down position and against resistance—suggests issues with the rotator cuff:

• Patient Profile: This condition is common in individuals between 35 and 75 years.
• Management: Begin with rest, NSAIDs/analgesics, and targeted physiotherapy. A subacromial injection might be considered if symptoms persist.
• Referral Considerations: If there’s only a transient response to injections or physiotherapy, it may be time to refer the patient to a specialist.

6. Recognizing Red Flags: When Urgent Referral Is Needed

Certain symptoms signal that immediate, more intensive evaluation is required. These red flags include:

• Signs of Infection: Red skin, fever, or systemic illness may indicate an infected joint.
• Acute Rotator Cuff Tear: A sudden onset of trauma with significant weakness might suggest a tear.
• Unreduced Dislocation: An obvious dislocation that has not been properly realigned.
• Suspicion of Tumour or Malignancy: Any unusual mass or swelling should prompt urgent investigation.

If any of these red flags are present, the patient should be referred urgently to secondary care.

Final Thoughts

This guide represents a practical approach for primary care settings to diagnose shoulder pain efficiently. The flowchart emphasizes the importance of:

• Targeted questioning and examination
• Understanding the typical age profiles for different conditions
• Starting with conservative management while being alert to red flags

Always remember: while such guides are invaluable for initial assessments, they are not a substitute for a comprehensive evaluation by a healthcare professional and no substitute for clinical reasoning. Early and accurate diagnosis is key to effective treatment and recovery.

Reference: Figure 2 from the Shoulder & Elbow article by Noorani et al.