Assessment of shoulder pain for non-specialists
BMJ 2016; 355 doi: https://doi.org/10.1136/bmj.i5783 (Published 07 December 2016) Cite this as: BMJ 2016;355:i5783
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This article, if it is supposed to be a guide for general practitioners, is just about useless. It is in the same category as the review of frozen shoulder published in the BMJ last year (1). Serious conditions (joint infection, dislocation, fracture, cancer, etc.) are pointed out, but how often would these be seen in general practice?
The ‘targeted shoulder examination’ with its emphasis on palpation is too vague to be of any help, and the four (three eponymous) ‘Simple tests to screen for common [shoulder] conditions in primary care’ are grossly inadequate as a means of reaching a diagnosis. The term ‘subacromial pain syndrome’ is meaningless and reminiscent of the long-discredited ‘peri-arthritis’.
As for ‘a pragmatic approach’ to treatment, the suggestions given are patronizing or almost laughable: ‘Consider offering the patient an information leaflet’, ‘Consider offering simple analgesia’, ‘Encourage as normal activity as the patient is able.’
Mr Aldridge says in the video: ‘Each specialist clinician often has their own idiosyncratic way of examining the shoulder.’ This is the problem!
How about learning to perform a standardized systematic clinical examination that will enable an accurate tissue diagnosis to be made in most cases? (2) (3)
symonds@tokyobritishclinic.com
1. BMJ 2016;354:i4162
2. Cyriax J, Textbook of Orthopaedic Medicine, Vol I. Diagnosis of soft tissue lesions. London: Baillière Tindall,1982: 127–158.
3. Ombregt L, Bisschop P, et al. A System of Orthopaedic Medicine. Churchill Livingstone, 2003: 291 – 303.
Competing interests: No competing interests
Very interesting and comprehensive article on shoulder examination detailing various conditions and diagnostic tests. The list of conditions in a shoulder pathology is elaborate and diagnosing not so easy in spite of all the special tests at one's disposal. This especially when the non-specialist general practitioner has only five or ten minutes per patient in his ever busy clinic. For a GP suspecting a shoulder pathology is good enough to make a referral to a specialist, as the sooner the patient is seen in secondary care the more specific is the diagnosis and the earlier is the treatment commenced. The usual pattern is a patient being treated for a year or two in primary care along with physiotherapy and adjunct modalities of therapy and then referred to a specialist.
Even a specialist takes a minimum of 20 minutes to half an hour to diagnose a condition with various scans and tests at his disposal, unlike in primary care where at the most one can get a X ray or some scan. As a shoulder surgeon, I'd rather see a patient with shoulder problem sooner rather than later and I am more comfortable discharging a patient back to primary care after the first consultation if no surgical treatment is necessary. Rather than pushing the burden and inundating primary care with an endless list of shoulder pathologies and the challenging job of diagnosing it with complex tests my thinking is for the GP to have skills to suspect a shoulder pathology and make a referral.
I see a similar pattern in physiotherapy shoulder specialist clinics where patients in the end are referred to a specialist anyway. GPs with special interests in shoulder or orthopaedic cases can tie up with specialist clinics in secondary care and run parallel or joint clinics. This model works better than patients going round in circles initially and then being seen in a hospital.
Competing interests: No competing interests
I read the recent review by Gray et al and was interested to see a ‘three step approach’ being recommended (1). I would point readers to the excellent review by Hermans et al which summarised the evidence supporting the use of the various special tests in diagnosing rotator cuff tendinopathy (2). This methodologically robust review concluded that a positive painful arc test result and a positive external rotation resistance test result were the most accurate findings for detecting rotator cuff tendinopathy; whereas the presence of a positive lag test (external or internal rotation) result was most accurate for diagnosis of a full-thickness rotator cuff tear. Notably the evidence to support the use of Neer’s and Jobe’s tests was demonstrably weaker. The use of the term ‘subacromial pain syndrome’ as an umbrella term to include entities such as ‘impingement’, ‘rotator cuff tendinopathy’ and ‘subacromial bursitis’ is a rather confusing way to explain this subject. Certainly shoulder pathology and pain is a complex topic with many overlapping entities (3), however in my opinion a far better umbrella term would be ‘rotator cuff tendinopathy’ as most clinicians would interpret to include the whole spectrum of cuff pathology from early painful tendinopathy without a tear to end stage massive full thickness tears. The term ‘impingement’ is disappearing from use as the evidence to support the mechanistic theory has evaporated in recent years (4).
1. Gray M, Wallace A, Aldridge S. Assessment of shoulder pain for non-specialists. BMJ (Clinical research ed.). 2016;355.
2. Hermans J, Luime JJ, Meuffels DE, Reijman M, Simel DL, Bierma-Zeinstra SA. Does this patient with shoulder pain have rotator cuff disease? The rational clinical examination systematic review. JAMA : the journal of the American Medical Association. 2013;310(8):837-847.
3. Dean BJ, Gwilym SE, Carr AJ. Why does my shoulder hurt? A review of the neuroanatomical and biochemical basis of shoulder pain. British journal of sports medicine. Feb 21 2013.
4. Papadonikolakis A, McKenna M, Warme W, Martin BI, Matsen FA, 3rd. Published evidence relevant to the diagnosis of impingement syndrome of the shoulder. The Journal of bone and joint surgery. American volume. Oct 5 2011;93(19):1827-1832.
Competing interests: No competing interests
Re: Assessment of shoulder pain for non-specialists
We thank all contributors for their comments on our article (1) and for highlighting some interesting areas for discussion.
We agree that, in an ideal world, the suspicion of relevant shoulder pathology alone in the primary care setting should be enough to warrant referral to a shoulder specialist. Speaking from author experience (namely a GP principal and a surgical trainee recently spending a four month period in the primary care sector) we fear that in the UK at least, we may not work in such an ideal world. Indeed, in the current economic climate of Clinical Commissioning Group (CCG) vetted referrals, a suspicion of shoulder pathology alone would not pass the CCG secondary referral test. Additionally, we agree that the “usual pattern of being treated for a year or two” before specialist referral is suboptimal.
It is for the above reasons that in the article we advocate an initial trial of management according to suspected pathology, but go on to suggest that an unsuccessful trial of management lasting more than 2-3 weeks should be a criterion for referral to secondary care (1, Box 4). Indeed, we should reiterate to readers that the ethos of our article is not to burden the GP, but rather to provide a framework to diagnose common shoulder complaints or at least place them into categories to direct initial management. We envisage that this approach will either lead to effective treatment in primary care preventing inappropriate referral or otherwise appropriate referral to secondary care without undue delay.
As an aside, the point of utilising GPs with special interests is a good one and where available, we agree, this resource is invaluable.
We are grateful for the comments highlighting Hermans et al (2) excellent review of tests for rotator cuff disease. Whilst we take the point regarding the choice of tests in our ‘three step approach’ to examination (1, Box 2; Figure 2), we must remind readers that our article considers the relatively vast differential diagnosis associated with shoulder pain in general, as opposed to rotator cuff disease alone. The rationale of our three step approach was therefore to screen for these multiple potential causes for shoulder pain in a memorable way, appropriate for the time pressured primary care context. Of course, additional tests as described by Hermans et al (2) could subsequently be used in secondary care as required.
We feel that Dierck et al’s ‘Sub-Acromial Pain Syndrome’ (3) is a reasonable approach to consider the causes of subacromial pain. Of course, some of these causes are not related to the cuff and this would be the main limitation of the suggested ‘rotator cuff tendinopathy’ umbrella term (e.g. biceps tendinitis, subacromial bursitis). However, as mentioned, we accept that this is a complex area with multiple potential approaches to diagnosis in this region.
Thank you again for your valuable contributions.
References
1. Gray M, Wallace A, Aldridge S. Assessment of shoulder pain for non-specialists. BMJ 2016;355:i5783.
2. Hermans J, Luime JJ, Meuffels DE, et al. Does this patient with shoulder pain have rotator cuff disease? The rational clinical examination systematic review. JAMA 2013;310(8):837-847.
3. Diercks R, Bron C, Dorrestijn O, et al. Dutch Orthopaedic Association. Guideline for diagnosis and treatment of subacromial pain syndrome: a multidisciplinary review by the Dutch Orthopaedic Association. Acta Orthop 2014;85:314-22.
Competing interests: No competing interests