Red flags for shoulder conditions
  • Trauma/dislocation
  • Signs of systemic illness including Polymyalgia Rhematica/Temporal Arteritis
    • Bilateral symptoms
    • Headaches
    • Blurred vision
  • Recent convulsion/electric shock (unreduced dislocation)
  • Trauma and acute pain with positive drop arm test
  • Referred pain into the neck, chest or abdomen
  • Referred visceral pain
    • Myocardial ischaemia
    • Shoulder tip pain (diaphragmatic irritation- spleen/ectopic pregnancy)
  • Consider Osteonecrosis in: smokers/steroid and alcohol use / haematological disorders.
Urgent shoulder referral

Patients with any of the following suspected should be sent to A&E:

  • Traumatic fracture or dislocation
  • Suspected infection
  • Recent tendon or ligament rupture

Urgent appointments should be made in a consultant led  clinic for patients with:

  • Rapidly worsening symptoms
  • Patient with acute history of trauma and under 40yrs (likely rotator cuff tear)
  • Shoulder pain with suspected or confirmed presence of cancer on imaging.
  • Constant unrelenting shoulder pain / especially unrelenting night pain in presence of cancer
  • Progressive or significant neurological loss suggestive of acute peripheral nerve compression

Immediate referral if infection or tumour are suspected (this is extremely rare)or if the condition is worsening very suddenly. If very urgent send to A&E.

Diagnoses include:

  • Trauma (# dislocation of clavicle at ACJ). Support with sling and refer to A&E. If obvious step (Grade IV or greater deformity) acute will need immediate surgery; Grade III should be referred directly to surgeons if active sportsperson.
  • Chronic # dislocation Grade IV or greater recommend surgical opinion.
  • Chronic Grade III - recommend surgical opinion if active/ sporting.
  • ACJ Sprain Grade I or II (no / minimum step).
  • ACJ Osteoarthritis (OA).


For ACJ ligament sprain and OA:

  • Optimal analgesia/ NSAIDs as appropriate.
  • Advice re: Rest, ice and shoulder girdle exercises.

If no improvement; suggest self referral or refer on to Physiotherapy Service for diagnosis (if needed) and treatment.


  • X-ray if trauma, tumour or infection suspected.
  • U/S and MRI not routinely indicated.
  • Consider guidelines in previous section.
  • Assessment / Diagnosis/Detailed advice/Acute injury management as required.
  • Mobilisations/ Muscle strengthening.
  • Consider steroid injection (if able to offer this service) or if not refer on to Interface Team.

If no improvement with comprehensive management consider referral to Interface Team.

Interface Team
  • Review previous assessment, diagnosis and management
  • Consider Steroid Injection.
  • If 2 steroid injections have not relieved symptoms (or favourable but temporary response) discuss options for onward referral with patient.
  • If patient fits the criteria below refer to Surgeon.

If patient does not wish to explore surgical option refer back to GP or consider Pain Consultant for advice regarding analgesia.



  • X -ray if trauma, tumour or infection suspected.
  • X-ray if no improvement after 3 months and/or prior to steroid injection.
  • If ACJ instability X-ray load bearing.
  • X-ray prior to surgical opinion.
  • U/S and MRI not routinely indicated.
Surgical Criteria

Referral to Orthopaedic Surgeon is appropriate in cases of complex diagnosis and management.

ACJ Surgery is indicated for:

  • Grade IV to Grade VI ACJ displacement (showing obvious stepping) acute or chronic presentation.
  • Grade III ACJ displacement (acute or chronic) may be considered for surgery especially if active sportsperson.
  • Severe OA  ACJ joint or ACJ  Osteolysis.

Consider the following:

  • willingness to undergo surgery
  • general health
  • understands recovery period post surgery

Surgical interventions include:

  • ACJ Stabilisation: Recovery period 6 weeks away from work and up to a year for full recovery.
  • Acromioplasty: Excision of lateral end of clavicle. Recovery period six weeks away from work and 3 to 6 months before full recovery.
  • Sub-acromial decompression (either arthroscopically or open surgery):  includes a combination of debridement, shaving off acromial spur, removal of calcific deposits and bursal resection. Recovery period up to  4-8 weeks away from work and up to 6 months for full recovery.


Note:  ACJ / GHJ and rotator cuff conditions often co-exist and therefore cross referencing pathways is essential.