Shoulder pain: diagnosis and management in primary care
BMJ 2005; 331 doi: https://doi.org/10.1136/bmj.331.7525.1124 (Published 10 November 2005) Cite this as: BMJ 2005;331:1124All rapid responses
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The precise patho-anatomical diagnosis of shoulder pain can be
difficult for GPs who do not have experience in the assessment of
musculoskeletal problems. A working diagnosis can be made by excluding
referred pain, palpating for localised tenderness, and assessing active,
passive and active resisted movements of all the muscles involved in
shoulder movement. The prevalence of Bicipital tendinopathy in the
community is underestimated as there is a tendency to miss the diagnosis
by not examining the active resisted movement of the Biceps. It is more
common in the 20-40 age group. Accurate diagnosis of the site and nature
of the shoulder problems determines the self-help management advice we
give to patients in primary care, the instructions on activity
modification, physiotherapy and injecting steroids. The outcomes from
steroid injections depend not only on the acuteness of onset and
underlying inflammatory pathology, but also on the accuracy of the
placement. The “evidence based” view that steroids have limited benefit
does not match the patient orientated evidence that matters. The latter is
far more important in the context of primary care.
An elaboration on the use and timing of X Rays, Ultrasound, and MRI
by the authors would have been useful, especially in the ethos of Practice
Based Commissioning as already open access to these investigations are
available in primary care. Two significant contributions to community
based “shoulder pain” management are from the Dutch College of GPs
guidelines on “Shoulder pain”(1) and the Cambridge study(2) . A further
useful prospective cohort study on outcomes was from Primary Care
Rheumatology Society.(3)
Bibliography:
1)NHG Practice Guidelines “Shoulder Complaints” (May 1999), accessed
via Google. nhg.artsennet.nl/upload/104/guidelines2/E08.htm
2)Vecchio P, Kavanagh R, Hazleman BL, King RH. Shoulder pain in a
community-based rheumatology clinic. Br J Rheumatol. 1995 May;34(5):440-2.
3)Croft P, Pope D, Silman A. The clinical course of shoulder pain:
prospective cohort study in primary care BMJ 1996;313:601-602
Competing interests:
None declared
Competing interests: No competing interests
This study was rather biased. There was no discussion on the value of
the role of musculoskeletal medicine. Every year doctors trained in
musculoskeletal medicine or medical osteopathy do thousands of successful
manipulations to those with chronic shoulder pain and obviate the need for
surgery.This is better for the patient , less traumatic and less
expensive.
Physiotherapy is very limited in prognosis however pain specialist
physiotherapists do have a good role to play here as do pain clinics in
the management of chronic pain.
Surgery should always be the last resport as like with back pain it does not
always lead to a significant improvement and in some cases can make
symptoms--including movement restriction.
Competing interests:
None declared
Competing interests: No competing interests
Was it not for a acupuncture course in Sri-lanka many years ago with the late prof. Anton Jayasuriya , then I would probably still not know what to do with the various shoulder-conditions described extensively in your paper and so common in general practice.
Really one just needs only one's thumb!! Far better still, one single needle.
In at least half of the patients with a "shoulder-condition" [with purpose I don't define frozen shoulder, rotator cuff etc], even longstanding cases, one can see a miraculous improvement within a minute or so of pressure [even better by needling] on the acupuncture point: stomach 38.
This improvement may be temporary and need to be repeated or just one treatment maybe enough.
A family member may be taught to repeat the treatment, if necessary [by pressure or repeating the needle.
If the treatment does not work at once, then it is not likely to work in the future.
Again within seconds or less then a minute the patient [and the doctor!!] maybe both amazed by the results.
If you wish to start today and see with your "own eyes":
The point is located halfway between the underside of the patella and the malleolus lateralis, one thumb-breadth lateral from the tibia.
Probably best to use the side of the effected shoulder. But the other side may work as well.
Try with strong pressure of your thumb or better use an acupuncture needle, if you have one and are a bit familiar with this.
I would be happy to receive your feedback.
bdmesq@gmail.com
Competing interests:
None declared
Competing interests: No competing interests
Shoulder pain is a common complain in patiens with Thoracic Outlet
Syndrome.There are 19 references in PUB-MED relating shoulder pain to
Thoracic outlet Syndrome.The diagnosis is made by the use of a triad of
physical findings (www.tos-syndrome.com),associated or not with the White
Hand Sign.
This triad of signs is not reported to be present or not in articles about
shoulder pain,therefore the diagnosis of Thoracic Outlet Syndrome is
frequently missed.
The triad of signs consist of 1)weakness of abduction and adduction oif
the fifth finger,2)paresthesias and/or paleness of the hand on elevation
of the upper extremities,
3)tenderness on thumb pressure in the supraclavicular area.
Competing interests:
None declared
Competing interests: No competing interests
Shoulder pain and acupuncture/CAM provision in the NHS
As a physiotherapist trained to practise acupuncture I was delighted
to read the letter regarding the use of the acupuncture point, ST 38 to
treat shoulder pain. This letter highlights two very topical points.
Firstly related to the continued debate regarding the cost effectiveness
of using acupuncture and CAM (complementary and alternative medicine) in
the NHS, which recently was subject of a review (1) and secondly the scope
in which current NHS clinicians practise. Thompson and Feder (2)
contributed to this, suggesting that complementary and alternative
interventions could be provided in a more cost effective manner by being
carried out by existing clinicians. Physiotherapists, who received many
referrals for musculoskeletal conditions, including shoulder pain,
incorporate manual therapy, exercise and electrotherapy into their
treatments. For those physiotherapists trained and accredited to practise
acupuncture, this offers another treatment modality and a very useful
skill for the treatment of pain. Physiotherapists can carry out a variety
of acupuncture training courses, such as completing an undergraduate
module, a short or long postgraduate course, or a specific Master of
Sciences course (MSc). The Acupuncture Association of Chartered
Physiotherapists (AACP) monitors the standards of training and practise
offered by chartered physiotherapists and has nearly 5,000 members.
It seems like a particularly cost effective procedure to have
physiotherapists, or other NHS clinicians, including doctors and nurses,
trained to provide acupuncture. The cost of training current NHS staff to
deliver acupuncture or possibly other CAM modalities, would I expect be
much less than employing additional therapists trained exclusively in
these modalities to deliver them.
In addition, when using the point ST 38, I find it beneficial for the
patients to actively rotate the shoulder within the limits of pain while
this point is being stimulated.
Reference List
(1). Canter PH, Coon JT, Ernst E. Cost effectiveness of
complementary treatments in the United Kingdom: systematic review. BMJ
2005;331:880-881.
(2). Thompson T, Feder G. Complementary therapies and the NHS. BMJ
2005;331:856-857.
Competing interests:
None declared
Competing interests: No competing interests