Shoulder Pain Care Pathway

Review in progress

Disclaimer: The guidance contains helpful primary care information for management of referrals and up to date referral criteria. These guidelines are locality specific to best reflect local services. This guidance does not override or replace the individual responsibility of healthcare and social care professionals involved in the delivery of care to make informed professional judgements appropriate to the circumstances of the individual.


This guidance refers to:

  • The management of patients presenting with Shoulder Pain

This guidance does not cover:

  • Under 18s (Wakefield)
  • Under 16s (North Kirklees)

Commissioning Statement:


Signs, Symptoms & Examination

'Frozen Shoulder'
  • Report a combination of pain and stiffness (loss of movement)
  • Typically, present between the ages of 40-60.
  • Female > Male
  • Common in diabetics and those with hypothyroidism
  • Equal restriction in both active and passive ROM – especially external rotation.
  • Must have a normal x-ray series to diagnosis (main differential is OA)

Glenohumeral Joint OA
  • Progressive onset of pain and stiffness (loss of movement)
  • May have a history of previous trauma to the affected shoulder (e.g. fracture, rotator cuff pathology or dislocation).
  • Consider possibility of an underlying inflammatory condition.
  • Typically, present in those over the age of 60.
  • Usually report pain at night.
  • Usually report difficulty with Activities of Daily Livings
  • Restricted active and passive ROM in all directions – especially external rotation.
  • May demonstrate crepitus
Rotator Cuff Related Shoulder Pain
  • Report pain in the anterolateral upper arm region (especially over the deltoid/biceps region).
  • Repetitive, unaccustomed, sustained or increased use of the shoulder (particularly above head) during occupation or activity.
  • Typically, present between the ages of 35-70.
  • Difficulty laying on the affected shoulder – can disturb sleep.
  • Pain upon elevation of the shoulder or taking hand behind back (e.g. putting on a jacket).
  • Usually presented with a well maintained active ROM in the shoulder.
Acromioclavicular Joint Related Shoulder Pain
  • Usually reports pain localised to the ACJ – can refer across the clavicle and within the C4 dermatome.
  • Pain on adduction of the arm across the body.
  • May have crepitus from the ACJ.
  • Diffuse pain over the anterolateral upper arm, scapula, deltoid and scapula region.
  • May report a focal dislocation (usually requires formal reduction) or subluxation (usually self-reduces).
  • May feel unstable or loose during movement.
  • May be fearful of moving the arm for fear of dislocation (apprehension).
  • May report trauma.
  • May report an absence of trauma and be able to voluntarily sublux or self-dislocate the joint.
  • May report a history of, or a family history of physiological laxity (Beighton Score)
  • May report a history or, or a family history of hypermobility syndrome (Brighton Criteria) or connective tissue disorder (e.g. Ehlers Danlos Syndrome).
Suspected Rotator Cuff Tear
  • Sudden pain and weakness after a traumatic incident e.g. falling on an outstretched hand or directly onto the point of the shoulder.
  • Difficulty actively moving the arm.
  • Typically occurs above the age of 40.
  • Unable to lay on the affected side.
  • Full passive range of motion.

Red Flags

Seek immediate or urgent specialist advice/treatment if:

  • Suspected Fracture/Dislocation/Infection - Refer to A&E
  • Acute rotator cuff tear/distal biceps rupture <8 weeks - Urgent Referral to Orthopaedics
  • Suspicion of malignancy (Red flags: unexplained weight loss, night pain, high inflammatory markers, smoker) - Refer to Secondary Care via 2 Week Rule


For additional information on signs and symptoms please click here - Signs and Symptoms

Rotator Cuff Related Shoulder Pain
  • Consider analgesia
  • Physiotherapy referral
Capsulitis / Stiff Shoulder
  • Consider analgesia
  • Consider one early capsular steroid injection by appropriately trained staff
  • Teach active and active assisted shoulder exercises
  • X-Ray required to exclude red flags (malignancy and Avascular Necrosis)
Acromio-clavicular Joint Pain (ACJ)
  • Exclude other shoulder pathology
  • Consider analgesia/ NSAIDS
  • Consider one steroid injection superiorly into ACJ
Gleno-Humeral OA
  • Analgesia
  • Consider X-Ray
  • Consider one injection into the gleno-humeral joint by appropriately trained staff member
  • Refer to CONNECT COMMUNITY MSK Service
Referred from Cervical Spine
  • Analgesia
  • Neck X-Ray not indicated


Referral Criteria

  • Red Flags
  • North Kirklees (MSK, Trauma and Orthopaedics and Physiotherapy)
    • All MSK referrals (excluding red flags) should be made to Connect Community MSK who will undertake clinical assessment and triage and refer on as appropriate (including to physiotherapy). Choice of provider will be offered following triage
    • Please click here to open the Clinical Decision Making Aid for further guidance on which part of Connect's pathway to refer into i.e. Physioline, Physio or CATs
  • Wakefield – MSK
    • Those not presenting with red flag symptoms or where diagnosis or treatment is unclear should be referred to Connect Community MSK who will undertake clinical assessment and treatment and/or refer on to physiotherapy or secondary care as appropriate. Choice of provider will be offered for onward referrals.
  • Wakefield - Physiotherapy
  • Wakefield – Trauma and Orthopaedics
    • Patients should be offered choice of provider for trauma and orthopaedics

Referral Requirements

  • For Shoulder Arthroscopy referrals documented evidence is required to demonstrate that the patient meets the commissioning statement criteria
  • For those patients who do not meet the eligibility criteria evidence of prior approval authorisation is required

Commissioning Statement:

  • Referrals for Shoulder Arthroscopy are subject to an eligibility criteria that must be met before a referral is made - please see Commissioning Statement for further information
  • For those patients who are not eligible for treatment under these policies consideration will be on an individual basis via the CCGs Prior Approval Process in accordance with NHS North Kirklees and NHS Wakefield CCG Commissioning Policy

Referral Instructions

  • e-Consultation is not currently available for this specialty
  • Referrals should be made via ICG to TRISH (if training has been undertaken) - See user guides (EMIS & S1) for further information.
  • For those Practices who have not received ICG training referrals should be made via eRS
  • Please identify speciality and clinic type

Supporting Information

Shared Decision Making

  • Patients have a right to make decisions about their care and should be fully informed about the options they face. They should be provided with reliable evidence-based information on the likely benefits and harms of interventions or actions, including any uncertainties and risks, eliciting their preferences and supporting implementation. Prior to referral for surgery the patient should understand their options and the benefits and risks and the likelihood of these occurring.

Patient information/Public Health/Self Care

Evidence/additional information

Assurance & Governance

  • This guidance was developed on: 03.2017
  • This guidance was ratified by: The OSCAR Assurance Group
  • Date ratified: 04.2017
  • Publication Date: 05.2017
  • Last Updated: 06.2018
  • Review Date: 03.2019
  • Ref No: MSK4 - 03.2017
Any feedback or suggestions to improve this guidance should be sent to:
Only the electronic version is maintained, once printed this is no longer a controlled document


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