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 A&E if infection or tumour is suspected or if the condition is worsening very rapidly.

  • Consider referred pain from Cervical or Thoracic Spine.
  • Exclude rotator cuff tear.
  • Consider trauma.

Diagnosis can be difficult in early stages:

  • Can be idiopathic or traumatic onset.
  • More prevalent with Diabetes.

Signs & symptoms may include:

  • Painful shoulder/ night pain.
  • Loss of passive range of movement/stiff end feel
  • X-ray normal in Frozen Shoulder.


  • 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.
  • Consider steroid injection, early (in the acute phase) for frozen shoulder  if undertaken as part of a package of care


X-ray if suspected:-

  • Trauma
  • Infection or tumour
  • Arthritis
  • Calcific tendinitis

U/S and MRI not routinely indicated

  • Consider guidelines in GP section.
  • Assessment / diagnosis / detailed lifestyle advice/ reassurance self-limiting nature of the condition.            
  • Active range of movement exercises/ mobilisations/ muscle strengthening.
  • Re-education of cervical spine and shoulder girdle movement.
  • Consider steroid injection if pain predominant (if able to offer this service) or refer to Interface Team.
  • If symptoms not improving, or worsening, consider options including referral to Interface Team.
Interface Team
  • Assessment to review diagnosis and previous management.
  • Consider steroid injection for Frozen Shoulder.
  • If steroid injection given and no improvement in pain; consider referral to Orthopaedic Consultant for diagnosis/opinion and management.
  • If stiffness predominant stage (approximately 6 months) and symptoms are not relieved discuss onward referral options with patient.
  • If patient fits criteria below consider surgical referral.
  • If patient does not wish to explore surgical option refer back to GP or Pain Consultant for advice regarding analgesia..


X-ray if suspected:

  • infection or tumour
  • Suspected Arthritis
  • Calcific Tendonitis
  • Pre-surgical referral


U/S and MRI not routinely indicated.

Surgical/Orthopaedic Criteria
  • Referral to Orthopaedic Surgeon is appropriate in cases of complex diagnosis and management.
  • Orthopaedic referral  generally not considered until the stiffness predominant phase (usually approximately six months)
  • Consider referral with patient if fits  surgical criteria and:
    • Willingness to undergo surgery
    • General health
    • Understands recovery period post surgery

Surgical interventions include:

  • Manipulation under anaesthesia +/- Arthroscopic capsular release. Recovery period 6 weeks away from work and  up to 4 months for full recovery

NB: Frozen Shoulder of post traumatic or insidious onset may be may be associated with other GHJ or ACJ joint disorders; e.g. rotator cuff impingement / tendinopathy; therefore cross-referencing the pathways is essential.