Referral criteria from primary care - shoulder pain

The patient should be referred to an orthopaedic specialist if there is

• pain and significant disability lasting more than six months
  • this is continuing pain and disability despite attention to occupation or sporting factors and, if appropriate, physiotherapy and steroid injections
• history of instability ("Has your shoulder ever partly or completely come out of joint?" "Are you worried that your shoulder might slip on certain movements?") or acute, severe post-traumatic acromioclavicular pain
• diagnostic uncertainty
• red flag criteria e.g.
  • history of cancer
    • symptoms and signs of cancer
    • unexplained deformity, mass, or swelling:? possible tumour
  • red skin, fever, systemically unwell - suggestive of infection
  • trauma, epileptic fit, electric shock; loss of rotation and normal shape - could the presentation represent an unreduced dislocation
  • trauma, acute disabling pain and significant weakness, positive drop arm test - possible acute rotator cuff tear
  • unexplained significant sensory or motor deficit:? neurological lesion > neurosurgical referral

Reference:

1. Mitchell C et al. Shoulder pain: diagnosis and management in primary care. BMJ 2005; 331:1124-8