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 via Interface if infection or tumour are suspected or if the condition is worsening very rapidly. If very urgent send to A&E.

Diagnoses include:

  • If 3rd degree sprain with dislocation of joint is present support with sling and refer to A&E.
  • Ligament Strain
  • Osteoarthritis (OA)


For Ligament Sprain and OA:

  • Optimal analgesia/ NSAIDs as appropriate
  • Advice re. Rest, ice and shoulder girdle exercises.
  • If no improvement after 2 weeks refer to Physiotherapy.

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


  • X-ray if trauma, infection or tumour suspected.
  • Consider guidelines in GP section.
  • Assessment / Diagnosis/Detailed lifestyle advice/ modification/Acute injury management.
  • Mobilisations/ Muscle strengthening.
  • If after 3 months symptoms are not relieved discuss onward referral with patient.
Interface Team
  • Assessment to review diagnosis and previous management
  • Consider Steroid Injection.
  • If 2 steroid injections have not relieved symptoms discuss onward referral with patient.
  • Consider referral back to GP or consider Pain Consultant for advice regarding analgesia.


  • X-ray if not previously performed.
  • X-ray if trauma, infection or tumour suspected.
  • X-ray pre-surgical referral.

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

There is no surgical option for sternoclavicular problems unless symptoms are due to trauma, infection or tumour.