Shoulder pain: diagnosis and management in primary care

Compromised shoulder movement due to pain, stiffness, or weakness can cause substantial disability and affect a person’s ability to carry out daily activities (eating, dressing, personal hygiene) and work.w1 Self reported prevalence of shoulder pain is estimated to be between 16% and 26%; it is the third most common cause of musculoskeletal consultation in primary care, and approximately 1% of adults consult a general practitioner with new shoulder pain annually. 1Occupations as diverse as construction work and hairdressing are associated with a higher risk of shoulder disorders.Physical factors such as lifting heavy loads, repetitive movements in awkward positions, and vibrations influence the level of symptoms and disability, and psychosocial factors are also important.w1 Recent studies suggest that chronicity and recurrence are common. 2 3 Common shoulder disorders exhibit similar clinical features, and the lack of consensus on diagnostic criteria and concordance in clinical assessment complicates treatment choices. 3w2-w5 This review proposes an evidence based approach using a simplified classification of shoulder problems, incorporating diagnostic techniques applicable to a primary care consultation and a “red flag” system to identify potentially serious disease. Sources and selection criteriaWe incorporated the latest consensus from systematic reviews and publications identified by a literature search through Medline, CINAHL, AMED, the Cochrane Library (Central, CDSR, HTA, DARE), Clinical Evidence, Best Evidence, Embase, British Nursing Index, PEDro, w6 Web of Science (social science and science citation indexes), and bmj.com.The search strategy included the terms “shoulder pain”, “rotator cuff disorder”, “rotator cuff tear”, “frozen shoulder”, and “primary care”.We found six published systematic reviews of interventions for shoulder disorders and one health technology assessment systematic review of diagnostic tests for the assessment of shoulder pain. 4-10A topic search within Clinical Evidence identified the section “Shoulder pain.” 11We identified and critically appraised other key publications in peer reviewed journals that were relevant to primary care or published since the latest systematic reviews.