Shoulder and Elbow

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MSK Physiotherapy for people with shoulder & elbow problems is provided as part of the NHS Lothian Integrated Shoulder & Elbow Pathway.

The NHS Lothian integrated shoulder & elbow pathway is a multidisciplinary collaboration. The service is based on the principles of the right care, from the right person, at the right time in the right place. The service offers a single point of access for patients with routine shoulder and elbow problems who require referral for their problem following failure to improve with initial primary care management.

Once within the service patients will be able to access all the multidisciplinary services that are required for their problem including physiotherapy, upper limb advanced practice physiotherapy, investigation, orthopaedic opinion and pain clinic opinion. There will be no need for patients to return to their GP to seek additional referrals or investigations for the shoulder or elbow problem. The service is underpinned by agreed pathways, escalation criteria and multidisciplinary clinics.

For clinical support and referral guidance see Shoulder & Elbow pathways | Right Decisions (scot.nhs.uk) .
This tool is based upon the resource developed at The Oxford Shoulder Clinic at the Nuffield Orthopaedic Centre and has been modified to take account of specific service delivery within NHS Lothian. The tool was co-created with General Practitioner Services, Orthopaedic Services, MSK Physiotherapy Services and Radiology services as part of the NHS Lothian upper limb steering group.

M.A & P.A. 15-09-23

Who not to refer/red flag presentations:	Serious pathology as a cause of MSK conditions is considered rare, but needs to be managed either as emergency or urgent referral to relevant secondary care service. Consider below & also see relevant body area tab for further specific information and advice. Please make sure all red flag concerns have been managed prior to any MSK Physiotherapy referral For further support & guidance and refer to: Shoulder & Elbow pathways \| Right Decisions (scot.nhs.uk)
Emergency conditions	Suspected septic arthritis Suspected unreduced shoulder dislocation Suspected fracture
Urgent conditions	Major spinal related neurological deficit/ worsening neurological deficit- suspected Suspected acute traumatic rotator cuff tear in the younger individual (<60 yr of age) Suspected inflammatory arthritis Suspected acute distal biceps rupture Suspected primary and secondary cancers
Consider serious pathology as a differential diagnosis if person presents with:	escalating pain and progressively worsening symptoms that do not respond to conservative management or medication as expected systemically unwell (fever, weight loss) night pain that prevents sleep due to escalating pain and/or difficulty lying flat
What not to refer – other:	Presence of significant red flags as detailed above Age <16 consider referral to AHP Physio – RHCYP Non MSK complaints Mod/severe glenohumeral/ elbow joint osteoarthritis in individual who wishes to consider surgical opinion- refer direct orthopaedics Loose body with locking- refer direct orthopaedics Chronic pain with a significant psychological/ psychiatric/ drug addiction element

Who to refer:

People with shoulder and elbow problems who have not responded to initial primary care management, do not have the presence of significant red flags or other exclusion criteria. Examples include undifferentiated/ non specific shoulder pain, other specific shoulder and elbow problems including frozen shoulder, calcific tendinopathy, rotator cuff related shoulder pain, early stage glenohumeral joint osteoarthritis, acromioclavicular joint disorders, tennis elbow, golfers elbow, biceps, triceps tendinopathy.

For further support & guidance and refer to:

Shoulder & Elbow pathways | Right Decisions (scot.nhs.uk)

How to refer:

Refer via SCI Gateway Referral “AHP-Physiotherapy” then choose local site.

Please provide as much detail as possible to help the triage process.

Important notes:

This single referral will gain access to the full multidisciplinary NHS Lothian Integrated Shoulder & Elbow service. Any consequent investigation/ surgical opinion/ pain service referral will be made within the service- the patient will not require to return to their GP. Please include relevant detail on your referral to allow the appropriate initial triage of the patient

Carefully consider red flags relating to the shoulder as the symptoms and signs associated with acute calcifictendinopathy often mimic malignant pain.

NHS Lothian Integrated Shoulder and Elbow Pathway

The NHS Lothian integrated back pain service is a multidisciplinary collaboration. The service is based on the principles of the right care, from the right person, at the right time in the right place.

The service offers a single point of access for patients with routine shoulder and elbow problems who require referral for their problem following failure to improve with initial primary care management.
Once within the service patients will be able to access all the multidisciplinary services that are required for their problem including physiotherapy, upper limb advanced practice physiotherapy, investigation, orthopaedic surgical opinion and pain clinic opinion. There will be no need for patients to return to their GP to seek additional referrals or investigations for the lumbar spine problem. The service is underpinned by agreed pathways, escalation criteria and multidisciplinary clinics.

The service has been designed following consultation with; General Practitioner Services, Orthopaedic Services, Pain Services, Physiotherapy Services and radiology services.

Support and guidance

For guidance and support refer to https://www.ckp.scot.nhs.uk//Published/PathwayViewer.aspx?fileId=5404

NHS Lothian patient website https://services.nhslothian.scot/ISES/Pages/default.aspx