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
  • Traumatic (Primary) Dislocation: Immediate referral via A&E of patient presents with obvious traumatic dislocation, consider recent convulsion/electric shock (unreduced dislocation).
  • Other non-primary dislocations/ subluxations (below) follow advice.
  • Post traumatic unstable shoulder may have structural damage, e.g. Labral tears (Bankart / SLAP lesions etc).
  • Atraumatic shoulder instability with structural problem e.g. lax joints or micro-trauma & minor instability.
  • Positional non-traumatic dislocation - abnormal motor patterning and capsular dysfunction.

NB: Dual joint pathology can exist +/- rotator cuff damage.


  • 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 or suspected OA.

  • Consider guidelines in GP section.
  • Assessment / Diagnosis /Detailed advice.
  • Acute Injury management where appropriate.
  • Rehabilitation / Muscle strengthening, shoulder & trunk / Motor patterning/ Mobilisations. This is the key management for non-traumatic instability.
  • If failed to improve despite comprehensive rehabilitation consider referral to Interface Team.

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

Interface Team
  • Assessment to review diagnosis and management.
  • Review specific tests for structural instability.
  • Consider onward referral as surgical criteria below.
  • 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 or suspected OA.
  • X-ray pre-surgical referral.
  • Post-traumatic Instability suspected labral tears: Consider MRI Arthrogram  for diagnosis;  required pre-surgical referral.
Surgical Criteria
  • Referral to Orthopaedic Surgeon is appropriate in cases of complex diagnosis and management
  • Atraumatic shoulder dislocation / instability very rarely requires surgery.
  • No shoulder surgical intervention is appropriate for patients with non specific shoulder pain or pain radiating from the neck.
  • Traumatic instability (2 dislocations within a year that does not respond to conservative treatment in six months should be referred with an MRI Arthrogram).
  • Discuss the following:
    • Willingness to undergo surgery
    • General Health.
    • Understands recovery period post surgery

Surgical  interventions include:

  • Shoulder Stabilisation interventions e.g. Bankart’s or SLAP repair or capsular shift.  Recovery period 6-8 weeks away from work, 4 to 6 weeks to driving and up to a year for full recovery.


NB: Shoulder instability with traumatic or non-traumatic onset may be may present with other shoulder complex disorders  e.g. rotator cuff disorders therefore cross referencing  the pathways can be  critical.