Download Management of Shoulder Disorders in Primary Care

REPORTS
ON
THE
RHEUMATIC
DISEASES
SERIES
5
Hands On
Practical advice on management of rheumatic disease
MANAGEMENT OF SHOULDER DISORDERS
IN PRIMARY CARE
Caroline Mitchell, MD FRCGP DRCOG
Senior Lecturer/General Practitioner, Academic Unit of Primary Medical Care, University of
Sheffield/Community Sciences Centre, Northern General Hospital, Sheffield
Introduction
Shoulder disorders cause pain, limit the ability to perform
many routine activities, and can significantly disrupt sleep.
Self-reported prevalence of shoulder pain is estimated at
between 16% and 26% in the general population.1 Shoulder
disorders are the third most common primary care musculoskeletal presentation (after back and neck pain) and,
while most people recover within 3 months, recurrence or
chronic symptoms may occur in a significant proportion of
patients.2
Several clinical tests (e.g. Hawkins, Neer, Yergason, Speed)
have been described to aid diagnosis of shoulder disorders.
However, research acknowledges a lack of consensus on
diagnostic criteria and a lack of concordance in clinical
assessment, even between musculoskeletal specialists.3,4
Furthermore, mixed shoulder disorders occur commonly
and over-differentiation between the numerous diagnostic
categories is unlikely to alter usual primary care treatment
and follow up.5
This report will focus on a simplified classification of
shoulder disorder, differential diagnoses and referral
pointers based on a clinical assessment appropriate within
primary care. Treatment choices linked to this classification
are presented alongside a summary of the evidence for
common interventions.
What are the risk factors?
Both incidence and functional impact increase with age.
Lifting heavy loads, repetitive movements in awkward
positions and/or prolonged elevation of the upper limb(s)
are all associated with the development of shoulder
February 2008 No 14
symptoms. Thus, occupations which usually involve such
physical risk factors are associated with a higher risk of
shoulder disorders. Recognised risk factors for adhesive
capsulitis (‘frozen shoulder’) include diabetes and prolonged
immobility, for example, after a stroke, after shoulder
trauma or surgery, or associated with cardiac disease or
surgery. In common with other painful musculoskeletal
disorders, psychosocial factors can influence outcomes such
as return to normal activities and work.6,7
Clinical assessment of the painful
shoulder
The consultation should take a holistic approach, which
includes an assessment of the functional impact of the
shoulder problem and explores psychosocial and occupational issues. Shoulder pain may arise from elsewhere, so
it is important to enquire about the general health of the
patient and symptoms arising from the neck, upper limbs,
axillae and chest.
History
The issues which should be covered are:
• Determining the onset (acute, sub-acute, recurrent),
site, nature, exacerbating and relieving factors and any
associated symptoms of the pain.
• Specifically enquiring about the relationship of the pain
to movement. Does it occur at rest? Is it nocturnal?
• Is there difficulty sleeping on the affected side? While
nocturnal pain may be due to difficulty finding a comfortable sleeping position, consider nerve root pain,
bony pain or malignancy, particularly if there is a history
of cancer and/or systemic symptoms.
Medical Editor: Louise Warburton, GP. Production Editor: Frances Mawer (arc). ISSN 1741-833X.
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• What is the impact on function of the joint? What
activities are impaired?
• Is the dominant or non-dominant arm affected?
• Is there neck or other upper limb pain?
• Are any other joints affected?
• Is there any history of injury, acute shoulder pain or
instability? Does the shoulder ever partly or completely
come out of joint or is there concern that it might slip on
certain movements?
• Enquiring about tasks undertaken at work and sporting
activities.
• Are there systemic symptoms of illness (fever, night
sweats, weight loss, generalised joint pains, rash, new
respiratory symptoms)?
• Is there a past history of shoulder pain or other musculoskeletal problems? What was the response to treatment?
• Enquiring about significant co-morbidity (diabetes,
stroke, cancer; respiratory, gastrointestinal, or renal disease; ischaemic heart disease).
• Checking current drug treatment and adverse drug
reactions.
Supraspinatus muscle
Acromioclavicular joint
Clavicle
Acromion
Coracoid
process
Scapula
Humerus
FIGURE 1. The anatomy of the shoulder.
TABLE 2. Shoulder pain: red flag indicators.
• Tumour: history of cancer; symptoms and signs of cancer; unexplained deformity, mass, or swelling, lymphadenopathy
• Infection: red skin, fever, systemically unwell
• Unreduced dislocation: trauma, epileptic fit, electric shock; loss of rotation; abnormal shape
• Acute rotator cuff tear: recent trauma, acute disabling pain and significant weakness, positive drop arm test
• Neurological lesion: unexplained wasting, significant sensory or motor deficit
Examination
The normal shoulder joint has the greatest range of
movement of any joint. Assess active, passive and resisted
movement in flexion, extension, abduction, adduction, and
internal and external rotation. Examine the neck, upper
limbs, axillae and chest wall for potential sources of referred
pain (Table 1).
Investigations
While plain radiography may be entirely appropriate to exclude fracture and/or dislocation in the context of trauma,
it is not usually indicated in the primary care assessment
of shoulder pain, unless, for example, malignancy is suspected. Malignancy and systemic illnesses are relatively rare
causes of shoulder pain, thus blood tests (full blood count,
erythrocyte sedimentation rate) should likewise only be
requested if there are red flag indicators.
TABLE 1. Examination of the shoulder joint.
• Inspect shoulders from the front, from the side and from behind for muscle wasting, swelling and deformity.
• Examine the neck, axillae, and chest wall and for lymphadenopathy.
• Assess range of movement of cervical spine.
• Palpate sternoclavicular, acromioclavicular and glenohumeral joints for tenderness, swelling, warmth and crepitus.
• Compare power, stability and range of movement (active, passive, resisted) of both shoulders.
• Observe scapular movement.
• Look for a painful arc (70–120° active abduction).
• Test passive external rotation (less than 50% range of movement compared to the unaffected side suggests a glenohumeral problem).
• Test for a significant rotator cuff tear (‘drop arm test’ – patient unable to support the weight of the affected arm abducted to 90°).
Causes of shoulder pain
Diagnosis should be based on a clinical assessment, summarised in the clinical algorithm opposite, which groups
patients according to the most common presentations.
The causes of shoulder pain may usefully be divided into
conditions associated with pain arising from the shoulder
joint and those conditions where the pain arises from
elsewhere (Table 3). This report will summarise the diagnosis and management of the three commonest shoulder
disorders presenting to primary care physicians: rotator
cuff disorders, glenohumeral joint problems and acromioclavicular joint problems. Referred mechanical neck pain
is usually easily differentiated from a shoulder disorder as
the pain and tenderness are localised to the neck and the
suprascapular area and referred to the shoulder and arm,
and also may be associated with upper limb paraesthesia.
Movement of the cervical spine and shoulder usually
produces more generalised upper back, neck and shoulder
discomfort.
Red flag indicators
Red flag indicators include symptoms and signs of systemic
disease, generalised or localised lymphadenopathy, history
of cancer, unexplained significant neurological deficit, and
concerning local features such as a palpable mass or bony
tenderness (Table 2).
2
FIGURE 2. Diagnosis of shoulder problems
with guidelines for initial management
Neck or shoulder or other?
s Symptoms localised to neck or shoulder?
s Move the neck and then
the shoulder
s Does this reproduce the pain?
Neck
RED FLAGS –
urgent referral
See Table 2
Neck/arm
Neck
Shoulder
Shoulder
Other neck or arm
Common age 35+
Common age 35+
Management
History of instability?
Management
s Perform neurological
examination. If positive
findings then refer
s Rest
s NSAIDs/analgesia
s Physiotherapy
s Has your shoulder ever partly or
completely come out of joint?
s Are you worried that your shoulder
may dislocate or slip in the joint
on sporting activity or on certain
movements?
s Rest s NSAIDs s Physiotherapy
Yes
to one
or both
No
Instability
Common age 10–35 years
Management
s Refer s Surgery
to both
Pain localised to the
acromioclavicular joint and
associated with tenderness?
Yes
Acromioclavicular joint
disease (uncommon)
Common age 30–50 years
Management
(there may be swelling)
s Refer
s Rest
s NSAIDs/analgesia s Surgery
s Consider cortisone
injection
No
Reduced passive external
rotation?
Yes
Glenohumeral joint
Frozen shoulder Common age 40–60 years
Arthritis (uncommon) Common age 60+
Management
s Cortisone injection
s Rest
s NSAIDs/analgesia s Refer
s Surgery
s X-ray
No
Pain on abduction with the
thumb down?
Yes
Rotator cuff/impingement
Common age 35–75 years
Management
Worse against resistance?
s Consider
s Rest
physiotherapy
s NSAIDs/analgesia
s Cortisone injection s Refer
s Surgery
Painful arc?
No
Other neck or arm pain
Common age 35–75 years
Management
s Physiotherapy
s Rest
s NSAIDs/analgesia s Refer
3
Adapted with kind permission of the
Oxford Shoulder and Elbow Clinic,
Nuffield Orthopaedic Centre NHS Trust, Oxford
prevalence of abnormalities, including partial and full
thickness tears. Thus there may be little or no correlation
between symptoms and functional impairment and the
type and severity of the tear.9
TABLE 3. Causes of shoulder pain.
Pain arising from the shoulder
• Rotator cuff disorders: rotator cuff tendinopathy, calcific tendinitis, impingement, subacromial bursitis, rotator cuff tears
• Glenohumeral joint problems: capsulitis (‘frozen shoulder’), arthritis
• Acromioclavicular joint problems
• Infection (rare)
• Traumatic dislocation
Glenohumeral joint problems
Adhesive capsulitis (‘frozen shoulder’) and glenohumeral
arthritis are characterised by deep joint pain, which causes
significant restriction of activities of daily living due to
impaired external rotation, for example putting on a jacket.
Sleep is often disturbed. In adhesive capsulitis, three phases
may be described over a period of 18–24 months:
Pain arising from elsewhere
• Referred pain: neck pain, myocardial ischaemia, referred diaphragmatic pain
• Polymyalgia rheumatica
• Malignancy: apical lung cancers, metastases
1. initial, gradual onset of diffuse and severe shoulder
pain, typically worse at night with inability to lie on the
affected side
2. a stiff phase with less severe pain present at the end
range of movement, global stiffness and severe loss of
shoulder movement
Common shoulder disorders
3. finally, a recovery phase with a gradual return of movement.
Rotator cuff disorders
In all rotator cuff disorders (Table 3), there is significant overlap of presenting symptoms and signs. The rationale for
grouping these disorders together is that treatment, management and follow up are similar.
During the stiffening phase of the process, the joint capsule
thickens and becomes stiff, rather like scar tissue. It is
physically difficult to penetrate at arthroscopy.10
Typically, there is significant restriction (over 50%) of passive
external rotation, compared to the unaffected shoulder.
Overall, global pain and restriction of all active and passive
movements are present.
Rotator cuff tendinopathy is the most common cause of
shoulder pain.5 There is often a history of physical risk factors
associated with occupational or sporting activities and pain
with overhead upper limb movements. Inspection may
reveal muscle wasting. On examination, pain is reproduced
on abduction with the thumb down and is worse against
resistance. While active and resisted movements are painful
and may be partially restricted, passive movements tend to
be full. The presence of a painful arc reinforces the diagnosis
of a rotator cuff disorder, but research has suggested that it
is neither specific nor sensitive as a clinical sign.8
Acromioclavicular joint problems
Acromioclavicular disorders in younger people are usually
secondary to injury, and sometimes joint dislocation may
occur. Acromioclavicular osteoarthritis may be the cause
of localised symptoms in the elderly, and in this age group
may also be associated with rotator cuff disorders such as
subacromial impingement and tendinopathy. Pain, tenderness and occasionally swelling are localised to the acromioclavicular joint. There is restriction of passive horizontal
adduction (flexion) of the shoulder, with the elbow extended
across the body.
The age of the patient, the mode of onset and character
of the pain (acute or subacute onset, history of trauma),
and functional impairment (exacerbation with overhead
activities and painful weakness of shoulder movements)
may indicate a diagnosis of rotator cuff tear rather than
tendinopathy. In young people there is usually a history of
acute onset after trauma. In the elderly, a rotator cuff tear
may be atraumatic, related to intrinsic degeneration of the
cuff or to attrition from bony spurs on the undersurface
of the acromion, or secondary to inflammatory arthritis.
A partial tear may exhibit similar features on clinical
examination to rotator cuff tendinopathy (muscle wasting
and painful weakness in resisted abduction may occur in
either condition). The ‘drop arm test’ (Table 1) has been
described as a useful test for a large or complete tear and
is an easy technique to incorporate into examination of the
joint.8
Treatment
For all shoulder disorders recommend regular analgesia,
encourage the patient to maintain activity (within limits),
advise on occupational issues and provide written ‘self-help’
information. Paracetamol is suitable as a first-line treatment
and may be supplemented by mild opiates such as codeine
phosphate. If no contraindications exist, non-steroidal antiinflammatory drugs (NSAIDs) may be used short term. In the
elderly, specifically counsel about the increased risk of upper
gastrointestinal side-effects and impact on renal function
and cardiovascular risk with NSAIDs, and in all patients the
risks of dependence and constipation with regular opiate
analgesics.
A study which used magnetic resonance imaging of the
shoulder joint in asymptomatic individuals found a high
4
Practical tips
Useful patient information:
• Arthritis Research Campaign information booklet, ‘The Painful Shoulder’:
www.arc.org.uk/arthinfo/patpubs/6039/6039.asp
• NHS Direct: www.nhsdirect.nhs.uk
Specialist/occupational health information:
• Work-related disorders of the upper limb. Reports on the Rheumatic Diseases (Series 5),
Topical Reviews 10. Arthritis Research Campaign; 2006 Oct:
www.arc.org.uk/arthinfo/medpubs/6630/6630.asp
• The Health and Safety Executive website provides useful guidelines for employers:
www.hse.gov.uk/msd/hsemsd.htm#uld
Rotator cuff disorders
ponse is good, the injections could be repeated up to three
times, at 6-weekly intervals. As there is no evidence that steroid injections are either beneficial or harmful in the presence of a rotator cuff tear, they should be avoided if the history and examination suggest a large or complete tear.
While relative rest in the early stages is appropriate for
rotator cuff disorders (including possible minor tears), the
patient should aim to return to normal activity as soon as
possible. Attention to occupational factors is important in
order to reduce the risk of long-term incapacity and loss
of employment. Changes may need to be made within the
workplace in order to facilitate early return to work, for
example a phased return to work or a temporary respite
from work involving repetitive shoulder movements or
heavy lifting.
Glenohumeral joint problems
The classical history of adhesive capsulitis is resolution after
18–24 months, although symptoms may persist for 3 years
or more, particularly in diabetic patients. The mainstay of
management is pain relief and maintenance of function,
and treatment can be tailored to the presenting phase. For
example, active physiotherapy alone may be distressing
and counterproductive if started in the early, painful phase
of the condition, but starting soon after intra-articular
corticosteroid injections may be of short-term benefit.13
Gentle mobilisation and strengthening exercises may
improve mobility and reduce disability in the later phases.
Overall there is a lack of high-quality clinical trial evidence for
common primary care treatments for rotator cuff disorders.
Many of the studies have been undertaken in a secondary
care setting and involved complex interventions which are
not easily reproduced in primary care. In a primary care
population, participants presenting with undifferentiated
shoulder disorders who were allocated to a physiotherapy
treatment group were less likely to re-consult with a GP than
those receiving steroid injections alone.11
Test your knowledge
‘Frozen shoulder (adhesive capsulitis)’: an on-line
learning module, including a short test and a
certificate to include in a personal development
plan. www.bmjlearning.com
Systematic reviews suggest equivalent short-term benefit for
physiotherapy (incorporating supervised exercise) and steroid injections in the management of shoulder disorders.12
Subacromial corticosteroid injections (see British National
Formulary www.bnf.org/bnf/), up to 10 ml in volume, may
relieve pain and thus facilitate rehabilitation, but the effect
may be small and relatively short-lived.12 If the initial res-
Acromioclavicular joint problems
If there is significant traumatic dislocation, refer the
patient. Otherwise, complete resolution of symptoms is
usual following rest and simple analgesia. Consider steroid injection of the joint if symptoms persist despite conservative management.
Rotator cuff
Other interventions
Acromioclavicular
joint
Clinical trials of acupuncture treatment for shoulder problems have tended to be too small and methodologically
diverse to provide robust evidence of benefit, apart from
some short-term pain relief after treatment. Occupational
factors have been implicated in the development of shoulder
disorders and there is evidence that the prognosis of both
neck pain and low back pain are influenced by individual
psychosocial factors (general psychological distress, fear of
movement, passive coping style). However, a systematic
review of a limited evidence base found multidisciplinary
biopsychosocial rehabilitation for shoulder problems in
adults of working age no better than ‘usual care’.14
Coracoid
process
(a)
(b)
FIGURE 3. Injection of the shoulder joint:
(a) subacromial approach, (b) anterior approach.
5
Referral criteria
References
The patient should be referred to an orthopaedic specialist
if there is:
1. Urwin M, Symmons D, Allison T et al. Estimating the burden of
musculoskeletal disorders in the community: the comparative
prevalence of symptoms at different anatomical sites, and the
relation to social deprivation. Ann Rheum Dis 1998;57(11):649-55.
• diagnostic uncertainty or any of the red flag criteria
summarised in Table 2
2. Winters JC, Sobel JS, Groenier KH, Arendzen JH, Meyboom-de Jong B.
The long-term course of shoulder complaints: a prospective study
in general practice. Rheumatology (Oxford) 1999;38(2):160-3.
• history of shoulder joint instability
3. Bamji AN, Erhardt CC, Price TR, Williams PL. The painful shoulder:
can consultants agree? Br J Rheumatol 1996;35(11):1172-4.
• acute, severe post-traumatic acromioclavicular pain
• pain and significant disability lasting more than 6
months, despite attention to known physical risk factors
and, if indicated, treatment with physiotherapy and
steroid injections.
4. de Winter AF, Jans MP, Scholten RJ, Deville W, van Schaardenburg
D, Bouter LM. Diagnostic classification of shoulder disorders:
interobserver agreement and determinants of disagreement. Ann
Rheum Dis 1999;58(5):272-7.
5. Ostor AJ, Richards CA, Prevost AT et al. Diagnosis and relation to
general health of shoulder disorders presenting to primary care.
Rheumatology (Oxford) 2005;44(6):800-5.
KEY PRACTICE POINTS
6. Bergenudd H, Lindgarde F, Nilsson B, Petersson CJ. Shoulder pain
in middle age: a study of prevalence and relation to occupational
work load and psychosocial factors. Clin Orthop Relat Res 1988;
(231):234-8.
• Self-help advice and discussion of physical contributory factors should be provided, in addition to analgesics.
7. Bongers PM. The cost of shoulder pain at work. BMJ 2001;322
(7278):64-5.
• Referral for physiotherapy may improve short-
term outcomes and reduce GP consultations for shoulder pain.
8. Calis M, Akgun K, Birtane M, Karacan I, Calis H, Tuzun F. Diagnostic
values of clinical diagnostic tests in subacromial impingement
syndrome. Ann Rheum Dis 2000;59(1):44-7.
• Steroid injections have a marginal short-term effect on pain.
9. Sher JS, Uribe JW, Posada A, Murphy BJ, Zlatkin MB. Abnormal
findings on magnetic resonance images of asymptomatic shoulders.
J Bone Joint Surg Am 1995;77(1):10-5.
• Mild trauma or overuse (before the onset of pain), early presentation and acute onset have a more favourable prognosis.
10.Norlin R. Frozen shoulder: etiology, pathogenesis and natural
course. www.shoulderdoc.co.uk 2005 Oct 13.
• Poorer prognosis is associated with increasing age, diabetes, severe or recurrent symptoms at presentation, and associated neck pain.
11.Hay EM, Thomas E, Paterson SM, Dziedzic K, Croft PR. A pragmatic
randomised controlled trial of local corticosteroid injection and
physiotherapy for the treatment of new episodes of unilateral
shoulder pain in primary care. Ann Rheum Dis 2003;62(5):394-9.
• Consider orthopaedic referral for surgical assessment when primary care measures fail.
12.Buchbinder R, Green S, Youd JM. Corticosteroid injections for
shoulder pain. Cochrane Database Syst Rev 2003;(1):CD004016.
Acknowledgement
13.Carette S, Moffet H, Tardif J et al. Intraarticular corticosteroids,
supervised physiotherapy, or a combination of the two in the
treatment of adhesive capsulitis of the shoulder: a placebocontrolled trial. Arthritis Rheum 2003;48(3):829-38.
This paper (including the tables) is derived from the following clinical
review: Mitchell C, Adebajo A, Hay E, Carr A. Shoulder pain: diagnosis
and management in primary care. BMJ 2005;331(7525):1124-8. www.
bmj.com/cgi/content/full/331/7525/1124.
14.Karjalainen K, Malmivaara A, van Tulder M et al. Multidisciplinary
biopsychosocial rehabilitation for neck and shoulder pain
among working age adults. Cochrane Database Syst Rev 2003(2):
CD002194.
6
COMMENT
Andrew J Carr, MA, ChM, FRCS
Nuffield Professor of Orthopaedic Surgery
Shoulder pain is a very common cause of disability in
the community. To a large extent it has been overlooked
both in terms of the amount of morbidity it causes
and also in terms of how it should best be managed.
This excellent overview summarises the approach to the
management of shoulder pain in primary care. It distinguishes the different types and patterns of shoulder
pain and provides guidelines for early management.
Significantly it distinguishes conditions involving the
rotator cuff (impingement and rotator cuff tear) from
disorders of the glenohumeral joint (frozen shoulder)
and osteoarthritis. The management strategy of these
conditions is different and it is important for doctors
in primary care to be able to distinguish them. This can
be done fairly straightforwardly with simple attention
to aspects of examination in the surgery. In primary
care complicated imaging is rarely needed for shoulder
disorders and is best left to severe cases or cases which
fail to respond to treatment and need management
in secondary care. A substantial number of operative
procedures are now available for shoulder disorders
and the review provides advice about the best time to
refer patients to secondary care.
A large number of questions about shoulder disorders
remain unanswered, for example:
1. Can a better treatment for frozen shoulder be found – for example are new anti-inflammatory
medications going to be useful?
2. How many injections should be given into the subacromial bursa or shoulder joint before they cause damage to tendon or other tissue?
3. Is accurate placement of an injection using ultra sound guidance a better way of managing dis orders of the subacromial bursa and rotator cuff?
4.
What is the best timing of management for rotator cuff tears? Should early surgery be advocated to prevent progression and the development of unmanageable massive tears?
Further research into both the natural history investigation and treatment of disorders including impingement, rotator cuff tear and osteoarthritis is currently
being supported by the Arthritis Research Campaign
(arc) and should allow us to give better advice to
patients in the future.
This issue of ‘Hands On’ can be downloaded as html or a PDF file from the Arthritis Research
Campaign website (www.arc.org.uk/about_arth/rdr5.htm and follow the links).
Hard copies of this and all other arc publications are obtainable via the on-line ordering system
(www.arc.org.uk/orders), by email ([email protected]), or from: arc Trading Ltd,
James Nicolson Link, Clifton Moor, York YO30 4XX.
7
2008 BSR Annual Meeting, Liverpool
Primary Care Day : 22 April 2008
SHOULDER PAIN
The British Society for Rheumatology, Primary Care Rheumatology Society and the arc Primary
Care Working Group are running a combined educational day on shoulder pain aimed at GPs,
rheumatologists and health professionals in rheumatology.
Topics include:
• Functional anatomy of the shoulder and common shoulder problems
• ‘Hands on’ examination session
• Operative treatment of shoulder problems
• Imaging of the shoulder – including a practical demonstration of
musculoskeletal ultrasound
• Sports injuries affecting the shoulder and their treatment/rehabilitation
For full details visit:
www.bsrconference.org.uk/primarycareday.html
Are you or do you know a GP registrar
with an interest in rheumatology?
Did you know about the
arc GP Registrar Prize?
One in five patients we see has a problem related to their
musculoskeletal system and arc is keen to foster interest
in this area in our future GPs. Audits, reports of service
developments and case studies are welcome entries.
Entries in by 7 JULY 2008. For an entry form and further
information please go to the arc website at:
www.arc-research.org.uk/forms/arcgpregistrarprize.asp