Orthopedics - Shoulder Pain (Adult)
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Shoulder Pain - Adult
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
- 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
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
- 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
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
- 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
- Chronic condition that
can be managed at the primary care level with intermittent specialty care
evaluation as needed.