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Assessment of shoulder pain for non-specialists

BMJ 2016; 355 doi: https://doi.org/10.1136/bmj.i5783 (Published 07 December 2016) Cite this as: BMJ 2016;355:i5783
  1. Matthew Gray, core surgical trainee1,
  2. Alasdair Wallace, general practitioner2,
  3. Stephen Aldridge, consultant trauma and orthopaedic and shoulder surgeon1
  1. 1Royal Victoria Infirmary, Newcastle Upon Tyne, UK
  2. 2Village Green Surgery, Wallsend, Tyne and Wear, UK
  1. Correspondence to: M Gray matthew.gray{at}doctors.org.uk

What you need to know

  • Shoulder pain is a common presenting complaint in primary care that can arise from the joint or be referred from elsewhere

  • Most diagnoses can be made from a systematic history and targeted examination

  • Most shoulder pathologies can be managed with treatment in primary care, but the non-specialist clinician needs to be aware of features in the history and examination that warrant referral

With more than 120 different “special tests” of the shoulder described,1 it is easy to see how its assessment can seem an enigma for non-specialists. Shoulder pain is common, and most cases will be managed in the community.2 Its prevalence in Dutch primary care is around 11 per 1000 patients seen each year,3 and as many as two in three people may experience it at some point in their life.4

Most diagnoses can be made from the patient’s history and examination considering relevant risk factors such as age, occupation, previous trauma, and relevant comorbidities. Here, we simplify the process of shoulder assessment to empower non-specialists evaluating a patient presenting with shoulder pain for the first time and provide an update on common shoulder pathologies.

Form a working diagnosis

Take a targeted history—For some guide questions, see box 1. Watch out for features that may warrant secondary care specialist referral, orthopaedic or otherwise (fig 1).5

Box 1: Questions for a targeted shoulder pain history

  • Shoulder pain analysis:

    • Onset, character, and duration of shoulder pain on motion, at rest, and whether it is present at night or affects sleeping?

    • History of trauma?

    • History of instability?

  • History of neck pain?

  • Other joints—Pain, stiffness, or swelling?

  • Occupation, hobbies, and sports—Manual or repetitive?

  • Constitutional symptoms—Such as weight loss, fever?

  • Relevant comorbidity—Such as diabetes, cancer, rheumatoid arthritis?

Fig 1 Red flags for shoulder pain that warrant urgent referral. Images adapted from BMJ Best Practice (http://bestpractice.bmj.com/best-practice/monograph/709.html), Physiopedia (www.physio-pedia.com/Shoulder_Dislocation), LITFL (http://lifeinthefastlane.com/a-funny-fracture/ …

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