Patient resources
NHS Lothian MSK Self Help Resources Webpage
Definition
Pain arising from structures within the subacromial space including the rotator cuff tendons and surrounding tissues. Previously referred to as shoulder impingement, tendinitis and bursitis however these terms are no longer recommended.
Typical signs and symptoms
- Pain is typically felt at the anterolateral shoulder, worse with lifting the arm, and on overhead activities
- There may be night pain but can usually find positions of comfort
- Commonly a history of change in loading activities at onset e.g. repetitive movements, heavy lifting, etc
- Examination findings may include: pain on active shoulder movements, a painful arc, passive movements should be well preserved, pain on resisted tests
Prevalence and risk factors
- Most common cause of shoulder pain presenting in primary care; up to 70% of all shoulder pain problems
- Common age 35 – 75 years
- Risk factors include: a change in load through the shoulder, certain medical conditions and metabolic factors (e.g. high cholesterol, inflammatory conditions, diabetes, obesity), lack of quality sleep, stress, long term and excessive alcohol intake, smoking, genetics
Prognosis/ risk factors for poor outcome
- Most patients improve with non-operative management
- Can improve within weeks to months, depending on contributing factors
- Symptoms can persist for several years
- Risk factors for poor outcome may include:
- higher pain severity and disability at baseline
- longer pain duration
- multi-site pain
- previous pain episodes
- anxiety and/or depression, stress
- adverse coping strategies
- poor self-efficacy
- low social support, unemployment
- low expectations of recovery
- lack of quality sleep
- lifestyle – e.g., smoking, alcohol, physical activity levels; medical co-morbidities including diabetes, inflammatory conditions, high cholesterol
Differential diagnoses
- frozen shoulder
- calcific tendinopathy
- acromioclavicular joint disorders
- shoulder instability
- glenohumeral joint osteoarthritis
Relevant standards and guidelines
NICE Clinical Knowledge Summaries: Shoulder Pain
BESS: Patient Care Pathways: Subacromial Shoulder Pain
P.A & M.A – 16-7-26
Who can refer:
- All primary care clinicians with relevant appropriate scope of practice i.e. GPs, Primary care MSK advanced practice physiotherapists, advanced nurse practitioners
- Patient self referral (resident of East Lothian HSCP, Edinburgh HSCP and West Lothian HSCP Where To Find Us – Musculoskeletal Physiotherapy)
- Secondary care consultants and associated teams
- MSK physiotherapists who identify patients with suspected serious conditions of the shoulder or elbow shoulder follow agreed pathways and processes NHS Lothian Integrated Shoulder & Elbow Service
Who and How to refer:
| Condition | Referral Type | Referral destination and process |
|---|---|---|
| Suspected septic arthritis/ septic bursitis | Same day | Orthopaedic registrar via Flow navigation centre on 03000 134000/ on call Orthopaedic registrar via switchboard 0131 242 1000 |
| Suspected facture or dislocation | Same day | Orthopaedic registrar via Flow navigation centre on 03000 134000/ on call Orthopaedic registrar via switchboard 0131 242 1000 |
| Suspected acute distal biceps rupture | Same day | Orthopaedic registrar via Flow navigation centre on 03000 134000/ on call Orthopaedic registrar via switchboard 0131 242 1000 |
| Suspected acute traumatic rotator cuff tear in the younger patient | Urgent | Orthopaedics via SCI gateway > Lauriston Buildings > Orthopaedics- Elbow & Shoulder |
| Suspected malignancy/ tumour specific to shoulder* | Urgent | Orthopaedics via SCI gateway > Lauriston Buildings > Orthopaedics- Elbow & Shoulder |
| Suspected inflammatory condition | Consider referral to Rheumatology – see RefHelp Rheumatology. | |
| Suspected neurological condition | Consider referral to Neurology – see RefHelp Neurology. |
* Please also see Sarcoma – RefHelp. If clinical assessment leads to a very strong suspicion of suspected underlying malignancy, with no specific localising signs or symptoms to suggest a specific underlying primary, consider recommendations and referral options detailed on GP Access to CT for Suspected Cancer (No Clinically Obvious Primary) – RefHelp
Who not to refer:
- Patients who have the presence of significant red flags/ suspicion of serious shoulder and elbow conditions or have suspected inflammatory condition – see serious shoulder & elbow conditions
- Age <16
Other considerations
It is key to distinguish a traumatic rotator cuff tear in the younger patient (typically <65) as this is a red flag and requires urgent referral to Orthopaedics. Atraumatic degenerative rotator cuff tears can occur in older patients. In these cases, patients usually experience pain and weakness in the absence of significant trauma.
For further information see associated sections
- Link to NHS Lothian patient internet site including patient information resources – https://services.nhslothian.scot/ISES/Pages/default.aspx
- Link to NHS Inform page shoulder problems https://www.nhsinform.scot/illnesses-and-conditions/muscle-bone-and-joints/self-management-advice/shoulder-problems
- Link to NHS Inform shoulder problems- Patient self help guide https://www.nhsinform.scot/self-help-guides/self-help-guide-shoulder-pain
- Link to NHS Inform page elbow problems https://www.nhsinform.scot/illnesses-and-conditions/muscle-bone-and-joints/self-management-advice/elbow-problems
- Link to intranet site NHS Lothian Integrated Shoulder and Elbow Service http://intranet.lothian.scot.nhs.uk/Directory/physiotherapy/NHSLIntegratedShoulderandElbowService/Pages/default.aspx
