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 is suspected or if the condition is worsening very rapidly. If very urgent send to A&E.
  • Rule out referred pain from Cervical Spine
  • Diagnosis symptoms may include:
    • Pain  and stiffness /reduced ROM
    • Painful interruption of sleep
    • Crepitus ‘noise’ and catching on movements
    • Painful Weakness.


  • 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 suspected infection or tumour.
  • X-ray if suspected Avascular Necrosis (AVN).
  • X-ray to confirm OA
  • Consider guidelines in GP section.
  • Assessment / Diagnosis/ Detailed lifestyle advice/ modification.
  • Exercises/ Mobilisations/ Muscle strengthening.
  • Re-education of cervical spine and shoulder girdle movement.
  • Consider steroid injection as part of package of care (if able to offer this service) or refer to Interface Team.
  • If not improved despite comprehensive conservative treatment discuss onward referral with patient refer to Interface team.
  • If surgical opinion not required consider functional rehabilitation.
Interface Team
  • Assessment to review diagnosis and management.
  • Consider Steroid Injection.
  • If steroid injection has not relieved symptoms discuss onward referral with patient if relevant to surgical criteria below.
  • If patient does not wish to explore surgical option refer back to GP or consider Pain Consultant for advice regarding analgesia.
  • If patient willing and able to consider surgery, refer to Surgeon with appropriate imaging.


  • X-ray to confirm diagnosis of OA.
  • X-ray pre surgical referral.
  • MRI scan if suspected cuff tear age over 50 years and prior to surgical referral.
  • X-ray and MRI scan if suspected AVN.
Surgical Criteria

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

  • Confirmed OA and failed comprehensive conservative management with intrusive pain and pain related disability.
  • Pain relief should be the main determinant for surgical intervention in comparison to recovery of strength and function.

Consider willingness to undergo surgery, general health and understands recovery period post surgery.


Surgical interventions include:

  • Shoulder replacement (Total shoulder Replacement or Hemi-arthroplasty) is undertaken for pain relief (some increase of range of movement is possible but surgery is not undertaken for this reason). Recovery period 4 weeks no driving, 8-12 weeks away from work, maybe 6 months or more for manual work and up to 12-18 months for full potential.
  • Reverse Total Shoulder Replacement- for ‘cuff arthropathy’ (when a massive degenerative tear is associated with painful OA of the GHJ -only performed in older people as lifespan of replacement is limited). Recovery period 8-12 weeks away from work and up to 12 -18 months for full potential.
  • Sub-acromial decompression / debridement – (either arthroscopically or open surgery) – includes various combinations of debridement, shaving off bony spurs, removal of calcific deposits and bursal resection. Recovery period up to  4-8 weeks away from work and up to 6 months for full potential.