18 Jul Shoulder pain and treatment

Shoulder pain and treatment discussed by local specialists Damian Clark (knee surgeon, NBT), Iain Packham (shoulder surgeon, NBT) and Hyunkee Kim (GP, Eastville Medical Centre).

What are the best shoulder pain examinations that GPs can do?

There are many shoulder pain tests with little agreement about which are best. With limited time available, it is good to have a few tests that you are confident performing.

• For ACJ pathology, I would recommend ACJ tenderness and pain with an O’Brien’s test. This is a scarf test but with the addition of the patient pushing up against resistance.
• For frozen shoulder or arthritis, look for a loss of passive movement compared to the other arm. Pay particular attention to external rotation in neutral and in abduction.
• For superior rotator cuff pathology, I would look for a Hawkins sign with an ‘empty can’ sign. This is a pain on internal rotation in abduction and pain and weakness when pushing up with the arm in abduction or elevation).
• These examinations can all be repeated following an injection to the relevant site. This helps confirm the diagnosis and provide treatment.

What sort of imaging should be obtained and which is better USS or MRI?

Imaging of the shoulder should always include plain XRs, even if you are considering ordering a scan (MRI or USS).

• Ultrasound is often considered to be more available and cheaper than MRI. It is good at confirming calcific tendonitis and significant rotator cuff tears.
• An MRI may be more useful in identifying and characterising pathology. MRI will also guide decision making and predict the potential outcome.
• If you are looking at intra-articular pathology or imaging post dislocation then the MRI should include intra-articular contrast (an arthrogram).

Are shoulder injections worth doing?

Injections around the shoulder can be helpful both for treatment and diagnosis. They also provide symptomatic relief to allow rehabilitation.

• Unguided injections are an acceptable standard of practice and avoid the extended wait for a guided injection.
• The placement of the injection needs to target the site of presumed pathology (GHJ/ACJ or subacromial space).
• Persistent symptoms generally indicate referral for further assessment, investigation and treatment.
• It is always worth documenting the immediate effects of the injection and repeating the examination. This may be diagnostically helpful.

Is there an acute shoulder clinic akin to the acute knee clinic that patients can be referred to? If so, what are the criteria for a referral?

There is now an acute shoulder clinic at Southmead Hospital. The clinic treats soft tissue shoulder injuries with a normal XR. and where an injury has led to a significant deterioration in shoulder problems.

Thanks, Iain and Hyunkee! Next up we will be asking Neil Upadhyay about back pain.