Shoulder Pain

Defintion

This chapter includes pain around the shoulder, upper arm and supraclavicular area.

When to refer

1. Unsure of diagnosis:
   Differential includes:
1. Impingement syndrome/Rotator cuff syndrome
2. Osteoarthritis of shoulder and acromio-clavicular joint
3. Frozen shoulder
4. Referred cervical spine pain - often extends in deltoid area
5. Referred pain from Pancoast Tumour
6. Polymyalgia rheumatica
2. When first line management has failed - see below
3. When investigations are abnormal
   

Investigations

• FBC
• ESR/PV
• Xray of shoulder and or acromioclavicular joint
• Consider CXR and cervical spine radiographs
• Rheumatology referral
  

First Line Management

Accurate diagnosis is of great importance. The mainstay of treatment is a local steroid injection and physiotherapy. If a single injection is of no benefit please refer. If there has been a significant improvement then repeat followed with referral if improvement not maintained. Please do not give more than 2 injections in 3 months before referral.

1. If painful arc a subacromial injection of 25mg of Hydrocortisone acetate mixed with 2 mls of 1-2% lignocaine.
2. For acromioclavicular OA joint injection with hydrocortisone acetate and lignocaine is often helpful as is physiotherapy.
3. Frozen shoulder - the course of this disease is often reduced by early glenohumeral injection. A subscapular and or supraclavicular nerve block is often helpful.
4. Referred neck pain should be treated with physiotherapy.
5. Impingement syndrome and rotator cuff problems need careful assessment and surgical intervention should be considered if symtoms fail to respond to conservative treatment including Rotator Cuff strengthening exercise programme.
6. Joint failure secondary to Osteoarthritis, rheumatoid arthritis, or crystal arthritis (Milwaukee shoulder) should be assessed for joint replacement surgery. Joint failure is defined as pain not controlled by simple analgesia, local treatment and/or deprives sleep.
   

Special Points

Wirral Hospital has recently appointed Mr Jeremy Kaye who will be joining the hospital in July 1996.
Mr Kaye has particular expertise in shoulder replacement.

Document Information
Expiry Date: 11/04/04
Author: Dr Tom Kennedy
Organisation: Arrowe Park Hospital