Exclude referred pain from the neck, diaphragm, heart, lungs, & polymyalgia rheumatica YES. NSAIDs/analgesics as required

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Muriel Stephens
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1 Shoulder Pain Clinical Presentation info for GPs who refer into PAH more info History and Examination Exclude referred pain from the neck, diaphragm, heart, lungs, & polymyalgia rheumatica more info for HCT MSK triage service more info Radiology (rarely indicated) info for patients Is it traumatic/ non-traumatic? more info RED FLAGS? No Red Flags Past medical history of dislocation/ subluxation of joint? YES NO NSAIDs/analgesics as required Refer to physiotherapy Refer all patients with new shoulder pain and a previous history of dislocation/subluxation of joint Primary Care / Initial selfmanagement Analgesics/NSAIDs Exercise sheet (see Information for patients) No improvement after 2-4 weeks Response to therapy? Consider GP administered steroid injection If not available in practice, consider referring to MSK Triage service (ESP) YES NO Refer to MSK Triage Discharge Physio to refer to MSK Triage MSK triage referral Assessment by ESP Self-management / life style advice Investigations as required MDT discussions with specialists Signposting to other MSK provision e.g. pain /physio Onward referral to secondary care if required

2 History and Examination Assessment of a Painful Shoulder Exclude referred pain from the neck, diaphragm, heart (e.g. ischaemic heart disease), lungs, and polymyalgia rheumatica (typically occurring in an elderly woman, presenting with bilateral shoulder pain associated with stiffness and loss of function and general ill health). Enquire about: Characteristics of the pain, for example onset, site of maximal pain, relationship of the pain to movement or rest (and whether it is present at night), and additional symptoms (e.g. instability, neurological symptoms). Functional impairment, such as whether the dominant or non-dominant arm is affected, effects on work or sport, and instability (e.g. history of dislocation). Systemic features (e.g. fever, night sweats, weight loss, generalized joint pains, rash). History of musculoskeletal or shoulder problems, or symptoms elsewhere. Significant co-morbidity (e.g. diabetes, stroke, cancer). Concomitant medications and potential adverse drug reactions. Perform an examination (comparing both shoulders). During examination, look for painful arc (pain between degrees of active abduction). If this is present, specific tests such as the Hawkin s test can help diagnose impingement.

3 RED FLAGS? Cancer/ systemic disease - weight loss, fever, constant pain day and night (not associated with movement), systemically unwell (consider also history of cancer/immunosuppression), mass/ swelling suggestive malignancy exit and manage/ refer as appropriate Severe trauma/ seizures followed by pain and loss of movement (e.g. dislocation/ acute cuff tear) refer to A&E/ fracture clinic?neuro lesion- unexplained wasting, significant sensory or motor deficit refer to neurology Features of inflammatory arthropathy other involved joints/evidence of morning stiffness > 2 hours refer urgently to rheumatology

4 Information for GPs who refer into PAH Spinal and knee MRIs should only be requested as a pre-cursor to surgery. If you think a patient requires an MRI as there may be a need for surgery, please refer the patients in the first instance to the Herts MSK Triage Service (Phone ). Patients will then be triaged by an Extended Scope Practitioner (ESP) who will be able to request an MRI if required. If you encounter any issues accessing the Extended Scope physio service or direct access to MRI for the red flag conditions specified in Appendix 1 of the guidance document linked to above, please call the Contract Hotline on or contracthotline.enhccg@nhs.net

5 Referral information for HCT MSK Triage Service The administration team are based at the New QE2 hospital. Appointments and General Enquires: or Fax: E- referral enquiries via the MSK e-referral administration on: Fax: Referral to the service is via the NHS e- referral system (previously Choose and Book). Electronic screening of referrals takes place on a daily basis by clinicians. The referrals are either referred directly to secondary care where they manage the Choose and Book process, or seen for clinical assessment by the team to decide the appropriate of care. Clinics for assessment are held at The New QE2, Hertford County Hospital, Cheshunt Community Hospital and Lister Hospital. The MSK Triage Service and the MSK Physiotherapy Service are both part of the whole integrated HCT MSK Service, and as such can refer directly to each other as appropriate. The MSK Physiotherapy Service is a team of therapists specialised in the treatment and management of Musculoskeletal Conditions and based over 6 sites in East and North Herts. (Referral for this team is currently paper referral but we are working towards referral by when we have transferred to full electronic records). The MSK Triage Service is a team of Extended Scope Practitioners (Physiotherapists by background) but with training and advanced skills for specialist assessment, referring for diagnostics and providing injection therapy. This team meets regularly for 3 MDT meetings with the appropriate Consultant Surgeons for the upper limb, lower limb and spine. Complex cases are discussed at these meetings to provide integrated care as necessary.

6 Information for patients and carers Referral to triage service - keywords_tid=msk&field_specialty_tid=all&=apply Arthritis Research UK shoulder pain leaflet - shoulder-pain.aspx Arthritis Research UK shoulder pain exercises and leaflet: British Pain Society leaflet, Managing your pain effectively using over-the-counter medicines:

7 Radiology Plain X ray only to confirm shoulder dislocation or shoulder arthritis Ultrasound and MRI should only be ordered by MSK triage and are rarely indicated

Clinical Presentation. Medial or Lateral Focal Swelling Consider meniscal Cysts. Click for more info. Osteoarthritis confirmed. Osteoarthritis pathway

Clinical Presentation. Medial or Lateral Focal Swelling Consider meniscal Cysts. Click for more info. Osteoarthritis confirmed. Osteoarthritis pathway Focal Knee Swelling Information for GPs who refer into PAH Spinal and knee MRIs should only be requested as a pre-cursor to surgery. Clinical Presentation If you think a patient requires an MRI as there