Shoulder Pain - Adult

Diagnosis/Definition

Shoulder pain, with or without symptoms of instability, stiffness, weakness, catching, crepitus, deformity, or paresthesias, not associated with acute fracture, in the absence of cervical spine or non-skeletal etiologies (such as cardiac or neurogenic).

Initial Diagnosis and Management

• History and physical exam, to include a careful neurological exam of the upper extremities.
• AP and axillary x-ray views of the shoulder are indicated as part of the initial diagnostic work up.
• MRI/CT/arthrogram not indicated as part of initial diagnostic work up.
• Diagnostic or therapeutic injection of local anesthetic and steroid, documenting site of injection (e.g. AC, subacromial, bicipital groove), type and amount of Rx.
• Sling and swathe (limited to maximum of 7 days).
• NSAIDs, appropriate use of light narcotic Rx for no more than 7 days in acute injuries.
• Activity modifications as required.

Ongoing Management and Objectives

• With the above plan and associated algorithm leading to diagnosis and treatment, resolution is expected in 3-4 weeks.  A specific diagnosis can be treated as above for 3-4 months, as long as slow improvement is occurring. Light narcotics only indicated for a short period after an acute injury or re-injury.
• If no improvement has occurred within 4 weeks, referral to specialty care is indicated.  Adjunctive studies other than x-rays are most appropriately ordered by the specialty care provider or after phone consultation recommendation.

Indications for Specialty Care Referral

• Abnormal x-ray and exam suggestive of tumor, infection, fracture, residual dislocation, or congenital deformity.
• No response to treatment within 4 weeks.
• Incomplete response to treatment within 3 months with initial slow improvement.
• Physical therapy as required for maintenance of ROM, strength, and for instruction in a self-therapy program. PT is authorized to consult specialty care is deterioration occurs.

Criteria for Return to Primary Care

• Resolution of symptoms, with or without surgical treatment.
• Completed specialty care evaluation demonstrating problem not amenable to surgical treatment but requiring ongoing care that may be accomplished at primary care level with the following guidelines recommended by the specialist in the health care record:
• Goals of further treatment, including pain relief, ROM, functional limitations, and anticipated long term course.
• Indications for specialty care reengagement such as deterioration or exacerbation requiring management or Rx exceeding ongoing management objectives guidelines outlined above.
• Chronic condition that can be managed at the primary care level with intermittent specialty care evaluation as needed.