Patient resources

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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

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.

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

Patient resources

NHS Lothian MSK Self Help Resources Webpage

Definition

Typically presents as insidious onset shoulder pain and stiffness persisting more than 3 months.  Characterised by fibrosis of the shoulder capsule. Can be either primary (idiopathic) or secondary. Previously known as adhesive capsulitis.

Typical signs and symptoms 

Pain dominant stage: Progressive shoulder pain, particularly at night and with sudden or unexpected movements. Night pain can be a dominant feature. Pain can be diffuse although usually localised to shoulder and upper arm. Progressive global loss of active and passive movement of the shoulder in a capsular pattern.

Stiff dominant stage: pain typically improves while capsular stiffness persists, especially loss of passive external rotation. Can range from mild to severe restriction.

Prevalence and risk factors

Lifetime prevalence of frozen shoulder is estimated to be 2-5% general population (8.2% male & 10.1 % female of working age). Up to 60% of people with diabetes may develop a frozen shoulder. The opposite shoulder can become affected within 5 years in up to 20% of patients.

Risk factors: Metabolic and hormonal changes including: diabetes, stroke, thyroid disorders, shoulder injury/surgery, Dupuytren’s disease, primary neurological conditions e.g. Parkinson's disease, cancer, cardiovascular disease, complex regional pain syndrome, smoking, obesity, autoimmune diseases, genetics (ethnicity and family history of frozen shoulder).

Prognosis/ risk factors for poor outcome

On average can take 2-4 years (mean 30 months) to reach a satisfactory recovery. Some cases can take longer with 10- 50% of patients reporting residual shoulder stiffness and disability up to 7 years.

Risks factors for poorer outcomes include diabetes, thyroid and metabolic disorders, inflammatory conditions, obesity, sleep deprivation, multi-site pain, previous pain episodes, anxiety and/or depression, adverse coping strategies, low social support, low self-efficacy, lifestyle factors e.g. smoking, alcohol, physical activity levels.

Other considerations

Rare in patients under 40 & over 70 years old.

Differential diagnoses

• glenohumeral joint osteoarthritis
• avascular necrosis
• malignancy (e.g., Pancoast tumour)
• subacromial pain/rotator cuff related shoulder pain
• shoulder dislocation
• fracture
• post stroke shoulder subluxation
• referred pain

Relevant standards and guidelines

BESS Patient Care Pathway: Frozen Shoulder

NICE Clinical Knowledge Summaries: Frozen Shoulder

Patient resources

NHS Lothian MSK Self Help Resources Webpage

Definition

Calcific tendinopathy (or calcific tendonitis) refers to a build up of calcium within a viable and well vascularised rotator cuff tendon, most often the supraspinatus tendon.

Typical signs and symptoms

Formative phase: may extend from 1 to 6 years and is usually asymptomatic.

Resorptive phase: extends from 3 weeks up to 6 months. During the acute resorptive phase the patient may present with sudden, insidious, severe shoulder pain that can spread to the arm, along with reduced movement/function and sleep disturbance due to pain.

• Usually unilateral, can be bilateral in up to 25% of cases
• More persistent symptoms may be similar to those of rotator cuff related shoulder pain
• Symptoms may wax and wane
• May have a non-capsular restriction in movement

Prevalence and risk factors

• Approximately 10% of patients with shoulder pain
• Mean age 30-60 years, slightly more prevalent in females than males
• Risk factors: uncertain; possibly some genetic and biological factors e.g. diabetes, gout

Prognosis/ risk factors for poor outcome

• Usually a self-limiting condition that resolves spontaneously
• May take weeks, months or years to resolve
• Those with endocrine disease/ biological contributing factors may respond more poorly to conservative measures

Other considerations

Consider red flags relating to the shoulder as the signs & symptoms associated with acute calcific tendinopathy often mimic malignant pain.

Dystrophic calcification may occur within a non-viable and poorly vascularised rotator cuff or in those with cuff tears; this is common to see with other signs of degenerative change and may not be the primary cause of symptoms, especially in older patients.

Incidental calcification can be found in 2.5-20% of 'normal' healthy shoulders on imaging.

Loose bodies: associated chondral defect; associated secondary osteoarthritis.

Differential diagnoses

Main differential diagnosis is Rotator Cuff Related Shoulder Pain. Patient history/ story/ onset is key in distinguishing. 

Patient resources

NHS Lothian MSK Self Help Resources Webpage

Shoulder Doc: Shoulder Arthritis

Versus arthritis: Osteoarthritis (OA) of the elbow and shoulder

Definition

Shoulder (glenohumeral joint) osteoarthritis (OA) is characterized by age related changes of articular cartilage and subchondral bone with narrowing of the glenohumeral joint.

Typical signs and symptoms

• Pain, stiffness and loss of function.
• Global restriction of active and passive movement in a capsular pattern.
• Reduced passive external rotation is key sign.
• May have crepitus on movement.
• Catching or locking may represent presence of loose fragments.
• Symptoms may fluctuate with acute-on-chronic flares.

A diagnosis of OA should be suspected if a person is 45 years or over with:

• Activity related joint pain.
• No morning joint-related stiffness, or morning stiffness lasting no longer than 30 minutes.
• Possible functional limitation.
• Examination findings may include: restricted and painful range of joint movement, bony swelling, joint deformity, mild synovitis or joint effusion, crepitus, and joint instability.

Prevalence and risk factors

5%-17% of patients with shoulder complaints. The prevalence of OA varies depending on the joint(s) affected, the person’s age, sex, socio-economic group, and comorbidities.  Primary OA is rare, secondary OA accounts for the majority of cases such as following trauma, surgery, osteochondritis dissecans and synovial chondromatosis.

Risk factors: advancing age, female > male, history of joint trauma/ fractures, obesity, lifestyle, occupational stresses, genetics, certain metabolic diseases e.g. diabetes, haemochromatosis, inflammatory arthritis; traumatic or degenerative rotator cuff tears.

Prognosis/ risks factors for poor outcome

• OA is not always a progressive condition.
• Symptoms may fluctuate with intermittent acute-on-chronic flares.
• Prognosis will depend on contributing factors - OA is a complex multi-factorial condition involving genetic, biological (age, obesity, metabolic health, genetics), lifestyle (physical activity, smoking, alcohol) and biomechanical (joint injury and structural changes) components.

Other considerations

• OA is largely a clinical diagnosis and doesn’t always require an x-ray.
• Arrange an x-ray if there is diagnostic uncertainty, atypical features, or sudden worsening symptoms.

Differential diagnoses

• Important to note that restricted passive external rotation can be seen in other disorders such as frozen shoulder, avascular necrosis and dislocation.

Relevant standards and guidelines

NICE Clinical Knowledge Summaries: Glenohumeral joint osteoarthritis

NICE Clinical Knowledge Summaries: Osteoarthritis

BESS: Patient Care Pathway: Glenohumeral Osteoarthritis

Patient resources

​NHS Lothian MSK Self Help Resources Webpage

Definition

• Symptoms arising from the acromioclavicular joint (ACJ)
• May be due to ACJ injury or pathology including osteoarthritis (OA) and osteolysis

Typical signs and symptoms

• Pain usually felt locally over the ACJ
• Typically made worse by raising the arm and arm across body movements
• There may be localised ACJ tenderness, limited range of movement due to pain, high painful arc, positive cross arm test, asymmetry of the shoulder contour

Prevalence and risk factors

ACJ OA:

• Usually affects people > 60 years; more common than GHJ OA
• Radiographic presence of ACJ OA is very common in people over 40 years but is often asymptomatic
• Risk factors: older age, female > male, history of joint trauma, obesity, lifestyle, occupational stresses, genetics, certain metabolic diseases e.g. diabetes, haemochromatosis

Osteolysis:

• Stress fracture of the outer end of the collarbone
• Usually caused by repetitive excess load to the outer clavicle such as activities seen in athletes and weightlifters
• Most common in people < 40 years
• Risk factors: repetitive excess load such as heavy and repetitive horizontal adduction, adduction, internal rotation, and forward/lateral flexion of the shoulder; sports including volleyball, tennis, basketball, swimming

Injury:

• May occur due to direct impact on the joint or a fall onto the outstretched arm
• Injuries range in severity from a mild sprain to complete disruption

Prognosis/ risk factors for poor outcome

ACJ OA:

• OA is not always a progressive condition
• Symptoms may fluctuate with intermittent acute-on-chronic flares
• OA is a complex multi-factorial condition involving genetic, biological (increasing age, obesity, metabolic health, genetics), and biomechanical (joint injury and structural changes) components

Osteolysis:

• Prognosis is generally excellent with conservative management of activity modification/ rest

Injury:

• Prognosis will depend on severity of injury and degree of instability

Other considerations

ACJ pain may exist concurrently with rotator cuff related shoulder pain; osteophytes from an arthritic ACJ may irritate the underlying rotator cuff tendons

Relevant standards and guidelines

NICE Clinical Knowledge Summaries: Acromioclavicular joint disorders

NICE Clinical Knowledge Summaries: Osteoarthritis

Patient resources

NHS Lothian MSK Self Help Resources Webpage

Derby Shoulder Instability Program

Shoulder Doc: Atraumatic Instability

Definition

Abnormal motion or position of the shoulder that can lead to pain, subluxation, dislocation and functional impairment, which happens without any history of a significant preceding injury (BESS 2019).

Typical signs and symptoms

• Vague onset of symptoms
• Absence of significant traumatic event in history
• Possibly a Beighton score suggestive of hypermobility
• More commonly experience subluxations than dislocations
• Feeling of shoulder insecurity or distrust on movement, but also can occur in resting postures
• Pain local to shoulder, commonly around long head of biceps
• Inability to perform overhead tasks due to pain, weakness or apprehension
• A small subgroup can develop involuntary muscle patterning habits

Prevalence and risk factors

• Around 4% of those with shoulder instability have atraumatic instability
• Younger patients <25 years old
• Female > male
• Risk factors: hypermobility, unbalanced muscle recruitment around the shoulder, overhead sports/ using shoulder at extremes of motion e.g. throwing activity, swimming.

Prognosis/ risk factors for poor outcomes

Between 50-80% of patients have a good outcome with non-operative management.  Prognosis will depend on classification and individual contributing factors including self-efficacy, fear avoidance and psychosocial factors.

Other considerations

A suspected unreduced dislocation is a red flag and should be managed as an emergency. See red flags pathway.

Traumatic instability should be assessed in an Orthopaedic clinic to determine management course.

Those with significant functional impairment can be resistant to usual conservative measures and may benefit from a multidisciplinary team approach to address psychosocial factors and other barriers to recovery.

Those with frequent emergency department attendance should be referred to specialist shoulder service.

Patients aged under 18 years, those with 20% absence from school, or 3-month absence from work should be referred to specialist shoulder service.

Differential diagnoses

• rotator cuff related shoulder pain
• calcific tendinopathy
• acromioclavicular joint disorders
• extrinsic sources such as the cervical spine, visceral referred pain, and peripheral nerve lesions.

Relevant standards and guidelines

BESS Patient Care Pathway: Atraumatic Shoulder Instability

Patient resources

NHS Lothian MSK Self Help Resources Webpage

Definition

• Shoulder pain with a presentation not in keeping with a specific diagnosis.
• Poor correlation between structure and pain.
• Biopsychosocial contributing factors may influence the pain experience.

Typical signs and symptoms

Non-traumatic shoulder pain and/or non-specific weakness and/or limited range of movement.  Many pain conditions do not have a structural cause or a specific diagnosis.

Prevalence and risk factors

Potential biopsychosocial contributing factors include, but are not limited to: medical comorbidities and metabolic factors including high cholesterol, inflammatory conditions, diabetes, obesity, hormonal, endocrine disorders, genetics; fear avoidance, pain catastrophising, low mood, low self-efficacy, low social support, low socio-economic demographics, education, low health literacy; lifestyle factors including physical activity levels, diet and nutrition, substance misuse, smoking, occupational stress, lack of quality sleep, stress.

Prognosis/ risk factors for poor outcome

Depends on the contributing factors, stage of disorder and individual's perspective.

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, 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; occupational stress. 

Other considerations

The International Classification of Functioning, Disability and Health (ICF) is a biopsychosocial model that can be used when considering assessment and management.  The MSK clinical translation framework can be helpful for people to understand factors contributing to musculoskeletal pain.

Relevant standards and guidelines

NICE Clinical Knowledge Summaries: Shoulder Pain

The above list of shoulder conditions is not exhaustive.  Please keep diagnosis under review and consider other potential causes.