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Shoulder pain - Management
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How should I manage acromioclavicular joint problems?
- If osteoarthritis of the acromioclavicular joint is thought to be causing the person's symptoms, see the CKS topic on Osteoarthritis for management recommendations.
- If the acromioclavicular joint pain is thought to be caused by a sprain following an acute injury:
- Advise rest and avoidance of cross-body shoulder adduction movements (e.g. golf swing, or weight lifting). Resume activities as tolerated, but avoid heavy lifting and contact sports for 8–12 weeks.
- Consider providing a sling for 5–7 days if an acromioclavicular joint sprain is suspected.
- Offer analgesia: paracetamol with or without codeine, or an oral nonsteroidal anti-inflammatory drug (NSAID, e.g. ibuprofen).
- Consider which drug has a more favourable balance of benefits and risks for the person.
- If an oral NSAID is indicated, consider gastroprotection with a proton pump inhibitor if the person is:
- At increased risk of gastrointestinal adverse effects.
- Subject to dyspepsia from oral NSAIDs.
- In people at risk of cardiovascular adverse events, ibuprofen up to 1200 mg per day or naproxen up to 1000 mg per day are recommended as first-line options.
- If there is no early benefit from an oral NSAID, discontinue its use.
- For more information on minimizing the risks from NSAIDs and when to consider gastroprotection, see the CKS topic on NSAIDs - prescribing issues.
- Consider referring to physiotherapy after 4–6 weeks if the person responds poorly to rest and analgesia.
Basis for recommendation
Approach to management
- Unless a traumatic dislocation is suspected, symptoms of acromioclavicular joint problems usually resolve with rest and simple analgesia [Mitchell, 2008].
Rest
- A New Zealand guideline on the diagnosis and management of soft tissue shoulder injuries and related disorders [NZGG, 2004], a review of the management of shoulder disorders in primary care [Mitchell, 2008], and a review of the management of chronic shoulder pain [Burbank et al, 2008] recommend rest and activity modification for acromioclavicular joint disorders.
- A New Zealand guideline recommends the use of a sling for 5–7 days to treat acromioclavicular sprains [NZGG, 2004].
Analgesia
- CKS found no evidence on the use of paracetamol, nonsteroidal anti-inflammatory drugs (NSAIDs), or codeine for the treatment of shoulder pain caused by acromioclavicular joint disorders, therefore the decision should be based on clinical judgement, taking into account the severity of the person's symptoms and comorbidities.
- For more information on the adverse effect profile and contraindications to prescribing NSAIDs, see the CKS topic on NSAIDs - prescribing issues.
- CKS has not recommended the use of stronger opioids in primary care as they are generally reserved for people with moderate-to-severe pain and long-term treatment should be undertaken with caution because of the potential for dependence [Iannotti and Kwon, 2005; Moskowitz and Blaine, 2005].
Physiotherapy
- CKS found no evidence to support the use of physiotherapy in people with acromioclavicular joint disorders.
- A New Zealand guideline mentioned that various methods of taping are used in the early management of acromioclavicular joint sprains, but there is no evidence to support this. This guideline also recommended a trial of rehabilitation after 4–6 weeks if there has been a poor response to rest and analgesia [NZGG, 2004].
When should I refer people with acromioclavicular joint disorders?
- Refer to an interface clinic (if available locally), or an orthopaedic surgeon or rheumatologist (depending on the reason for referral) if there is:
- Diagnostic uncertainty.
- Failure to maintain function despite conservative measures.
- Inadequate improvement after 3 months of primary care treatment.
- Consider earlier referral for certain groups for whom shoulder pain is particularly disabling (e.g. athletes involved in overhead sports, or people involved in heavy manual labour).
- Consider urgent referral to the appropriate specialist if red flag features (including suspected dislocation) are present.
Additional information
- Many people with musculoskeletal problems do not need to be treated in hospital and may receive faster and more appropriate care in a community setting. These people, whose needs could be better met elsewhere, are often referred to hospital rheumatology and orthopaedic services, and this may increase the waiting times for those who do require specialist hospital care, particularly orthopaedic surgery.
- Multidisciplinary Clinical Assessment and Treatment Services (or interface clinics) aim to reduce referrals to hospital while ensuring that people are directed towards the most appropriate services and clinicians working at the interface between primary and secondary care. They provide efficient, rapid assessment, diagnosis, and treatment of people with a variety of musculoskeletal problems. Healthcare professionals involved may include physiotherapists, GPs with a special interest in musculoskeletal problems, and clinical nurse practitioners.
[DH, 2006]
Basis for recommendation
- A New Zealand guideline advises considering referral to an orthopaedic specialist if a sprain is suspected and there is an inadequate improvement after 3 months, or earlier for certain groups who may benefit from surgical stabilization [NZGG, 2004]. Feedback from an expert reviewer suggests that rheumatologists may manage this group of people with corticosteroid injections.
- The recommendation to refer immediately if dislocation is suspected or red flag features are present is based on a review of the management of shoulder pain in primary care [Mitchell, 2008].
Prescriptions
For information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC) (http://emc.medicines.org.uk), or the British National Formulary (BNF) (www.bnf.org).
Paracetamol +/- codeine
Age from 16 years onwards
Paracetamol tablets: 500mg to 1g up to four times a day
Paracetamol 500mg tablets
Take one or two tablets every 4 to 6 hours when required for pain relief. Maximum of 8 tablets in 24 hours.
Supply 100 tablets.
Age from 18 years onwards
Paracetamol tablets: 1g up to four times a day
Paracetamol 500mg tablets
Take two tablets every 4 to 6 hours when required for pain relief. Maximum of 8 tablets in 24 hours.
Supply 200 tablets.
Codeine 30mg tablets: add on to paracetamol if required
Codeine 30mg tablets
Take one or two tablets every 4 to 6 hours when required for pain relief. Maximum of 8 tablets in 24 hours.
Supply 84 tablets.
Standard oral nonsteroidal anti-inflammatory drugs (NSAIDs)
Age from 16 years onwards
Ibuprofen tablets: 400mg three times a day
Ibuprofen 400mg tablets
Take one tablet three times a day.
Supply 84 tablets.
Ibuprofen tablets: 400mg four times a day
Ibuprofen 400mg tablets
Take one tablet four times a day.
Supply 112 tablets.
Ibuprofen tablets: 600mg three times a day
Ibuprofen 600mg tablets
Take one tablet three times a day.
Supply 84 tablets.
Ibuprofen tablets: 800mg three times a day
Ibuprofen 400mg tablets
Take two tablets three times a day.
Supply 168 tablets.
Diclofenac sodium e/c tablets: 25mg three times a day
Diclofenac sodium 25mg gastro-resistant tablets
Take one tablet three times a day.
Supply 84 tablets.
Diclofenac sodium e/c tablets: 50mg three times a day
Diclofenac sodium 50mg gastro-resistant tablets
Take one tablet three times a day.
Supply 84 tablets.
Naproxen tablets: 250mg twice a day
Naproxen 250mg tablets
Take one tablet twice a day.
Supply 56 tablets.
Naproxen tablets: 500mg twice a day
Naproxen 500mg tablets
Take one tablet twice a day.
Supply 56 tablets.
Gastrointestinal protection with standard NSAID or coxib
Age from 16 years onwards
Omeprazole capsules: 20mg once a day
Omeprazole 20mg gastro-resistant capsules
Take one capsule once a day.
Supply 28 capsules.
Lansoprazole capsules: 15mg each morning
Lansoprazole 15mg gastro-resistant capsules
Take one capsule each morning (on an empty stomach).
Supply 28 capsules.
Lansoprazole capsules: 30mg each morning
Lansoprazole 30mg gastro-resistant capsules
Take one capsule each morning (on an empty stomach).
Supply 28 capsules.
Esomeprazole tablets: 20mg once a day
Esomeprazole 20mg tablets
Take one tablet once a day.
Supply 28 tablets.
Pantoprazole e/c tablets: 20mg once a day
Pantoprazole 20mg gastro-resistant tablets
Take one tablet once a day.
Supply 28 tablets.
© NHS Institute for Innovation and Improvement