Acute & MSK · Full case

Shoulder Pain

NICE CKSPainful arcNG12 red flags

Rotator cuff = commonestSubacromial pain (rotator cuff disorders — tendinopathy, impingement, partial tear) is the most common cause of shoulder pain in primary care; painful arc 60–120°; passive range usually preserved; first-line is analgesia + graded physiotherapy

Frozen ≠ cuffAdhesive capsulitis (frozen shoulder) restricts PASSIVE external rotation — the single most useful sign separating it from rotator cuff disease (where passive range is preserved). Strongly associated with diabetes; check HbA1c

Passive ER lostLoss of passive external rotation with the elbow at the side = capsular pattern = frozen shoulder or glenohumeral OA. This is the pivotal examination finding — do not skip passive movement

Pancoast → CXRApical (Pancoast) lung tumour can present as shoulder pain ± Horner's syndrome (ptosis, miosis, anhidrosis) and small-muscle wasting of the hand (T1). Smoker + weight loss + atypical pain → urgent chest X-ray within 2 weeks (NICE NG12 lung cancer)

Bone pain red flagUnexplained, progressive, deep bony shoulder pain — especially night pain, prior cancer, or systemic features — needs imaging: NICE NG12 bone sarcoma (very urgent X-ray 48h in young people) / suspected bony metastases in adults

Acute traumatic tearA sudden cuff tear after trauma with true weakness (cannot initiate abduction / external rotation) in a younger or active patient is time-critical — early surgical opinion (ideally within ~2 weeks) gives the best repair outcome

Hot joint + fever = 999Septic arthritis of the glenohumeral joint is a surgical emergency — hot, swollen, exquisitely painful joint with systemic upset; do not inject; urgent admission for aspiration and IV antibiotics

Injection = adjunctSubacromial / intra-articular corticosteroid injection gives short-term pain relief for subacromial pain and the painful phase of frozen shoulder — it buys a window for rehabilitation; it is not a cure and does not replace exercise therapy; limit repeated injections

📋 Clinical Stem — Shoulder Pain

A 54-year-old self-employed plasterer and lifelong smoker with 8 weeks of worsening right shoulder pain, worse reaching overhead and lying on it at night, now limiting his ability to work

Marcus Bevan, 54, a right-handed self-employed plasterer, attends with 8 weeks of right shoulder pain that has come on gradually without any single injury. It is worse when he reaches overhead or out to the side — difficult in his job — and it wakes him when he rolls onto it at night. Over-the-counter ibuprofen helps a little. He has had to turn down work and is worried about money. He is a 20-pack-year smoker, still smoking. On direct questioning he mentions he has lost "maybe half a stone" over the last couple of months without trying, which he puts down to "not eating properly since the shoulder." He asks whether he can "just have a scan and a steroid injection to sort it out" so he can get back to work.

This stem tests the ability to: take a structured shoulder history that separates a mechanical pattern (rotator cuff / subacromial pain) from a capsular pattern (frozen shoulder) and from sinister causes; recognise and act on the red-flag combination of a heavy smoker + unexplained weight loss (apical/Pancoast lung tumour — NICE NG12 urgent chest X-ray); examine the shoulder properly including passive external rotation and a neurological screen; manage the common presentation conservatively (analgesia + physiotherapy first-line, with a realistic role for injection); and handle the patient's specific request for "a scan and an injection" with shared decision-making rather than simply acquiescing or refusing. The SCA challenge is balancing his understandable wish for a quick fix against the need to exclude a serious cause first.

Scenario A — Subacromial pain / rotator cuff (commonest) Gradual onset, painful arc 60–120°, pain on overhead reach, night pain lying on it, passive range preserved, Hawkins–Kennedy positive. Management: analgesia (topical/oral NSAID), activity modification, graded physiotherapy as cornerstone, consider subacromial steroid injection for short-term relief; review 6 weeks; refer if not improving or weakness/large tear.

Scenario B — Frozen shoulder (adhesive capsulitis) Type 2 diabetic; global stiffness; cannot reach back pocket or fasten bra; PASSIVE external rotation markedly reduced; X-ray normal. Management: explain natural history (freezing→frozen→thawing, often 1–3 years), analgesia, maintain movement, physiotherapy, intra-articular steroid in the painful freezing phase; optimise glycaemic control; refer if not settling (hydrodilatation / capsular release).

Scenario C — Acute traumatic rotator cuff tear Fell onto outstretched hand / pulled on shoulder; sudden pain then weakness; cannot initiate abduction or external rotation; positive drop-arm. In a younger or active patient this is time-critical — urgent shoulder surgical opinion (ideally within ~2 weeks) for consideration of early repair; analgesia and avoid prolonged immobilisation.

Scenario D — Pancoast / apical lung tumour (red flag) Smoker; unexplained weight loss; deep aching shoulder/arm pain not fitting a mechanical pattern; ± Horner's syndrome (ptosis, miosis, anhidrosis), ± wasting of the small muscles of the hand (T1). Action: urgent chest X-ray within 2 weeks (NICE NG12 lung cancer); if abnormal → 2-week-wait lung cancer pathway. Do not anchor on "muscular shoulder pain."

Scenario E — Acromioclavicular joint (ACJ) Pain localised to the top of the shoulder over the ACJ; worse with cross-body (scarf) movement and high arc 170–180°; point tenderness over ACJ; often prior heavy lifting or a previous fall onto the point of the shoulder. Management: analgesia, activity modification, physiotherapy; ACJ-targeted injection or surgery if persistent.

Key variables to adapt for Onset (gradual mechanical vs sudden traumatic vs insidious sinister); range pattern (painful arc with preserved passive range = cuff; lost passive external rotation = frozen shoulder / OA); age (instability in the young, OA and cuff tears in the older); diabetes (frozen shoulder, worse prognosis); systemic/cancer features (Pancoast, bony metastases, myeloma); occupation (overhead/manual work); hand dominance and impact on work and income; bilateral shoulder-girdle pain + stiffness + raised inflammatory markers in over-50s → consider polymyalgia rheumatica.

Steps:

Step 1

History Taking — Pain Pattern · Stiffness vs Weakness · Red-Flag Screen · ICE

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The shoulder history has one organising question: is this a mechanical problem (rotator cuff / subacromial pain), a capsular problem (frozen shoulder or glenohumeral OA), or something that is not really the shoulder at all (referred neck, referred cardiac/diaphragmatic, or a sinister cause such as an apical lung tumour or bony metastasis)? The two discriminating threads to pull are the pattern of pain (mechanical and movement-related vs deep, constant, unremitting) and the balance of stiffness vs weakness. Marcus's job, his hand dominance, and the impact on his income matter as much as the biology. The single most important safety task here is not to anchor on "muscular shoulder pain" in a smoker who has lost weight.

🎓 SCA framing — take the request seriously, but examine and safety-net first

"I can hear how much this is getting in the way of your work, and I absolutely want to get you a plan that works — including a scan or an injection if they're the right thing. To make sure I point those at the right target, let me ask a few questions and examine the shoulder first, because that changes which test actually helps you."

Marcus has arrived with a fixed solution ("scan + injection"). The skill is not to refuse it, nor to simply hand it over, but to align with his goal (back to work) while keeping the right to examine and exclude a serious cause first. The weight loss + smoking detail is the hinge of the case.

1A — Open question then pain characterisation

Question	Why it matters	Changes what?
🟢 OPEN QUESTION"Tell me about the shoulder — when it started, what it stops you doing, and what a bad moment looks like."	The open question lets the pattern declare itself: a gradual, movement-related, overhead-and-night pain points to rotator cuff / subacromial pain; a global "everything is stiff, I can't reach behind me" points to frozen shoulder; a deep, constant, boring pain that is present at rest and unrelated to movement is the one that should raise the hair on the back of your neck. Marcus volunteers overhead pain, night pain lying on it, and an 8-week gradual onset — a mechanical story. But he also volunteers unintentional weight loss, which does not belong to a mechanical story and must be actively pursued.In SCA: a candidate who asks only "where does it hurt?" gathers the minimum. A candidate who maps onset, mechanical vs rest pain, night pain, stiffness vs weakness, the functional cost, and screens for systemic features has the data to both diagnose and exclude.	Mechanical/overhead → cuff. Global stiffness → frozen shoulder. Constant rest pain → red flagWeight loss + smoker → CXR
Onset and mechanism"Did it come on out of the blue, or after a particular injury or pull? Was there a moment it suddenly gave way?"	Gradual atraumatic onset over weeks fits rotator cuff tendinopathy / subacromial pain and frozen shoulder. A sudden tear during a fall, a heavy lift, or a pull — followed by weakness — suggests an acute rotator cuff tear, which (in an active patient) is the one mechanical diagnosis that is time-critical for surgical repair. A fall onto the point of the shoulder suggests ACJ injury or fracture.	Atraumatic gradual → cuff/frozen. Sudden trauma + weakness → ?acute tear (urgent ortho). Fall onto point → ACJ/fracture.	Mechanism narrows the structureAcute tear + weakness → early surgical opinion
Pain pattern — movement vs rest, and night pain"Is it mainly when you move it a certain way, or is it there even when you keep still? Does it wake you at night?"	Movement-triggered pain that eases with rest = mechanical (cuff, ACJ). Night pain lying on the affected side is classic — and common — in subacromial pain and frozen shoulder, so it is NOT by itself a red flag. The concerning pattern is constant, deep, unremitting pain that is present at rest, unrelated to position, and not eased by anything — that is the pain of tumour, infection, or referred visceral disease, not of a cuff.	Mechanical/positional → benign MSK. Constant rest pain unrelated to movement → investigate for sinister cause.	Rest pain quality separates MSK from sinister
Stiffness vs weakness — the key discriminator"Is the problem more that it's stiff and you can't move it, or that it's weak and won't do what you ask — can you reach up to a high shelf, and can you fasten a seatbelt or reach your back pocket?"	This single question separates the two big diagnoses. Stiffness — a global loss of movement so that even someone else moving the arm is restricted (especially reaching the back pocket / hand-behind-back and external rotation) — is the language of frozen shoulder. Weakness — the arm is the right shape and moves freely when supported but cannot generate force, or cannot initiate abduction — is the language of a rotator cuff tear. Pain that limits movement but with preserved passive range is subacromial pain.	Global stiffness (esp. external rotation) → frozen shoulder. True weakness → cuff tear. Pain-limited, range preserved → subacromial pain.	Drives the examination and the diagnosis
Functional impact, occupation and hand dominance"You said you plaster for a living — which arm, and what can't you do now? How much work have you had to turn down?"	Marcus is a right-handed plasterer with right shoulder pain — overhead, sustained, loaded work is exactly what a subacromial problem cannot tolerate, and the condition therefore threatens his livelihood directly. Hand dominance, occupation, and the financial stakes shape both urgency and the management plan (e.g. the value of a steroid injection to buy a working window, and the realistic pace of return to manual work). This is core ICE/social territory, not an afterthought.	Dominant-arm manual worker: higher functional stakes; injection may have a role to enable rehab and work; realistic graded return.	Occupation shapes urgency, injection role, return-to-work planSelf-employed: income loss is a major stressor
🚩 Systemic / sinister screen"Have you lost weight without trying? Any fevers or night sweats? Have you ever had cancer? Any cough, coughing blood, or change in your voice? Any numbness or wasting in the hand?"	This is the safety core of the consultation. Marcus is a 20-pack-year current smoker with unintentional weight loss — that combination, with shoulder/arm pain, must trigger active exclusion of an apical (Pancoast) lung tumour, which classically refers pain to the shoulder and arm and can produce Horner's syndrome and wasting of the small muscles of the hand. Separately, a history of cancer (breast, prostate, lung, kidney, thyroid, myeloma) with new deep bony shoulder pain raises bony metastasis. Fever with a hot joint raises septic arthritis.	Smoker + weight loss + atypical pain → urgent CXR (NG12 lung). Prior cancer + bony pain → imaging for metastasis. Fever + hot joint → emergency.	Hot joint + fever → admitSmoker + wt loss → urgent CXR (NG12)Bony pain + cancer hx → 2WW imaging

1B — Red flags: shoulder pain that is not a shoulder problem

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Red Flags — exclude before labelling shoulder pain "mechanical"

Red flag	Why dangerous	Action
Smoker + unexplained weight loss + atypical shoulder/arm pain (± Horner's, ± hand wasting)	Apical (Pancoast) lung tumour invades the brachial plexus and sympathetic chain — it refers pain to the shoulder, scapula and inner arm, and may produce Horner's syndrome (ptosis, miosis, anhidrosis) and wasting of the T1-supplied small muscles of the hand. It is repeatedly missed as "frozen shoulder" or "muscular pain." Marcus fits the at-risk profile exactly.	Urgent chest X-ray within 2 weeks (NICE NG12 lung cancer); if abnormal → 2-week-wait lung pathway
Unexplained, progressive, deep bony pain — night pain, prior cancer, or systemic upset	Constant bony pain unrelated to movement, worse at night, in someone with a cancer history (breast, prostate, lung, kidney, thyroid) or systemic features may be a bony metastasis or, in younger patients, a primary bone sarcoma. The shoulder girdle (proximal humerus, scapula) is a recognised site.	Urgent imaging: NICE NG12 — very urgent X-ray (48h) for suspected bone sarcoma in children/young people; suspected metastases in adults → urgent X-ray ± specialist referral
Hot, swollen, exquisitely painful joint with fever / systemic upset	Septic arthritis of the glenohumeral joint is a surgical emergency — joint destruction occurs within days and mortality is significant. Suspect in the unwell patient, the immunosuppressed, the recently injected joint, or IV drug use. Do NOT inject a possibly septic joint.	Same-day acute admission — joint aspiration and IV antibiotics; do not inject
Significant trauma — deformity, inability to move, or neurovascular deficit	Fracture (proximal humerus, clavicle) or glenohumeral dislocation after a fall or high-energy injury. An anterior dislocation may injure the axillary nerve (deltoid sensation/power); vascular compromise is limb-threatening. Inability to bear any movement after trauma needs imaging.	Urgent X-ray; A&E for reduction if dislocated; document neurovascular status
Acute cuff tear with true weakness in an active patient	A sudden tear with inability to initiate abduction or external rotation (positive drop-arm) is time-sensitive — the repair window is best within a few weeks, after which the tendon retracts and the muscle fatty-infiltrates, reducing surgical success.	Urgent shoulder surgical opinion (ideally within ~2 weeks); analgesia; avoid prolonged immobilisation
Exertional / left shoulder-tip pain, or shoulder-tip pain with abdominal signs	Referred visceral pain: cardiac ischaemia (exertional, with breathlessness/sweating), or diaphragmatic irritation (subphrenic, gallbladder, ruptured ectopic/spleen → left shoulder-tip pain, Kehr's sign). A normal shoulder examination with a story that does not fit the shoulder should redirect you.	Treat as cardiac/abdominal emergency as indicated — ECG, observations, urgent assessment

1C — PMH · Drug & social history

🧬 PMH / FH — what changes the differential

Factor	Why it matters	Impact
Diabetes (and thyroid disease)	Frozen shoulder is strongly associated with diabetes — it is more common, more severe, more often bilateral, and slower to resolve. Thyroid disease and Dupuytren's also associate. A diabetic with global shoulder stiffness should make you think capsulitis early.	Diabetic + capsular pattern → frozen shoulder likely; check HbA1c; optimise control; counsel on prolonged natural history; injection raises glucose transiently — warn.
Previous cancer (breast, prostate, lung, renal, thyroid, myeloma)	New deep bony shoulder pain in anyone with a cancer history is a metastasis until proven otherwise — the proximal humerus and scapula are recognised sites. Do not attribute it to degeneration without imaging.	Prior cancer + bony pain → urgent X-ray ± specialist imaging; NICE NG12 suspected metastases pathway; check bone profile/calcium.
Inflammatory arthritis / polymyalgia features	Bilateral shoulder-girdle pain and morning stiffness lasting >45 minutes in someone over 50, with raised ESR/CRP, suggests polymyalgia rheumatica; an inflammatory mono/oligoarthritis may also present at the shoulder. These are not subacromial pain.	Bilateral girdle stiffness + raised inflammatory markers → consider PMR (steroid-responsive); inflammatory pattern → rheumatology.
Previous shoulder dislocation / instability	A young patient with a history of dislocation and a sense the shoulder "slips" or "feels like it will come out" has instability, which is managed quite differently (rotator-cuff and scapular stabiliser rehab ± stabilisation surgery), not as impingement.	Instability history → apprehension testing; physiotherapy focused on stabilisers; surgical referral if recurrent.

💊 Drug history · Social history

Factor	Why it matters	Impact
Smoking history	Marcus's 20-pack-year current smoking is the pivotal social-history fact in this case — it transforms "shoulder pain + weight loss" into a mandatory lung-cancer exclusion. Smoking also impairs tendon and post-surgical healing.	Smoker + weight loss → urgent CXR (NG12); offer smoking-cessation support; relevant to healing and surgical risk.
NSAID use, GI/renal/cardiac risk	NSAIDs are useful for subacromial pain but carry GI, renal and cardiovascular risk; check what he is already taking OTC, co-morbidities, and whether gastroprotection is needed before prescribing a course.	Prescribe NSAID at lowest effective dose/shortest course; consider topical NSAID; add PPI if GI risk; review renal function.
Anticoagulants / antiplatelets	Relevant if a corticosteroid injection is being considered (bleeding/haematoma risk) and to the differential (spontaneous haemarthrosis).	On anticoagulant → care with injection; not an absolute contraindication but assess risk.
Occupation, income and overhead loading	Self-employed manual worker: no sick pay, strong pressure to keep working, and a job that mechanically aggravates a subacromial problem. The social reality drives the management plan and the patient's expectations.	Plan must address return-to-work realistically; injection may buy a working window; activity modification advice tailored to plastering.

1D — ICE

💭 Ideas

"What do you think is going on in there — and where did the idea of a scan and an injection come from?"

Marcus has a mechanical model ("I've worn it out / pulled something") and a fixed solution. Surfacing his idea lets you align with what is right in it (it probably IS a cuff problem) while gently keeping room for the safety work. It also reveals whether anyone — a mate, the internet — has told him an injection is a quick fix, which sets up the expectations conversation.

😟 Concerns

"What's the worst this could be, in your mind? And what's worrying you most day to day?"

His foreground concern is money and work. His background concern — which he may not voice — could be the weight loss, or a family member who had cancer. Eliciting it lets you frame the chest X-ray not as alarming but as thorough ("because you smoke and you've lost a bit of weight, I want to be careful and check your chest — it's the responsible thing to do"), which keeps him on side rather than frightened.

🎯 Expectations

"You mentioned a scan and an injection — tell me what you're hoping each of those would do for you."

Naming his expectation explicitly is the heart of the SCA challenge. He wants to be back at work. An MRI is not first-line for typical subacromial pain; an injection has a real but limited role. The skill is to honour the goal, explain what actually helps (physiotherapy as the cornerstone, injection as an adjunct, imaging targeted by the examination and the red-flag screen), and reach a shared plan — not to simply say yes or no.

1E — Psychosocial context

For a self-employed plasterer, a painful dominant shoulder is not a nuisance — it is a threat to income with no sick pay behind it. That reality drives the "just give me a scan and an injection" request: it is a request to get back to earning. Treating the request dismissively ("we don't scan these") misses the person; granting it uncritically misses the medicine. The consultation that works names the pressure, commits to a plan that gets him working again as fast as is safe, and earns the few minutes needed to examine the shoulder and check his chest.

💷 Income insecurity

No work means no money this week. This urgency is legitimate and should be worked with, not against — agree a clear timeline, a realistic graded return, and what would justify an injection to bring that forward.

"I want to get you back plastering as quickly as we safely can. Let's make a plan with a timeline — and if an injection is the thing that gets you working sooner, we'll absolutely consider it once I've checked it's the right shoulder problem."

🚭 The smoking + weight-loss conversation

This must be handled without frightening him, but without minimising it. Frame the chest X-ray as routine thoroughness given two specific facts (smoking, weight loss), not as "I think you have cancer."

"Two things make me want to check your chest with a simple X-ray — that you smoke, and that you've dropped some weight without meaning to. Nine times out of ten it's nothing, but it's exactly the situation where I'd be failing you if I didn't look."

💉 Managing the injection request

An injection is a legitimate adjunct, not a cure, and works best alongside rehabilitation. Explain that honestly so he is not disappointed when the pain returns without the exercises.

"An injection can take the edge off for a few weeks and give us a window — but on its own it tends to wear off. The exercises are what actually fix the underlying problem, so I'd want to do both, not the injection alone."

🛠️ Modifying the work, not just stopping it

"Rest" is unrealistic. Practical load modification — reducing sustained overhead time, alternating tasks, using a hawk/trowel differently — keeps him earning while the shoulder settles.

"Completely stopping isn't realistic for you, I get that. So let's talk about which bits of the job hurt it most — the overhead ceiling work — and how to space those out while we get the shoulder stronger."

😴 Night pain and mood

Disrupted sleep from night pain erodes mood and coping, which feeds back into the money worry. Acknowledge it and treat it (analgesia timing, sleeping position) as part of the plan.

"Being woken every night when you're already stressed about work is grinding — let's get the pain settled enough to sleep, because that helps everything else too."

🚭 Cessation as an opportunity, not a lecture

The visit is a teachable moment, but the timing must be sensitive — offer support, don't moralise, and connect it to what he cares about (healing, breathing, the X-ray result).

"Whenever you feel ready, I can help you stop smoking — it helps tissues heal and it's the single best thing for your chest. No pressure today; the offer's always open."

🎓 SCA Checkpoint — Step 1TasksRelating to OthersGlobal Skills

Key phrases that score

"Is it more that it's stiff and won't move, or weak and won't pull? Can you reach your back pocket?" — the one question that separates frozen shoulder from a cuff problem.

"Because you smoke and you've lost some weight without trying, I want to check your chest with an X-ray — it's the careful thing to do." — names the red flag without alarming.

"I want to get you back to work fast — let's make sure a scan or injection is aimed at the right target first." — aligns with his goal while keeping clinical control.

Deductions

Anchoring on "muscular shoulder pain" and missing the smoker + weight-loss red flag
Simply agreeing to an MRI and injection without examination or safety-netting
Refusing the request flatly without exploring or offering an alternative plan
Not asking about stiffness vs weakness — the core discriminator
Ignoring the financial/occupational reality driving the consultation

🔴 Red

Red flag missed; MRI/injection agreed uncritically; no systemic screen; no stiffness-vs-weakness question; occupation ignored

🟠 Amber

Mechanical history taken; weight loss noted but not acted on; ICE partial; injection request neither explored nor planned; CXR not arranged

🟢 Green

Pattern characterised; stiffness vs weakness clarified; smoker + weight-loss red flag identified and CXR planned; ICE all three; injection/scan request explored and reframed; occupation and income integrated; safety-net

Step 2

Triage — Emergencies · Urgent Referral & 2WW · Routine Primary Care

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Most shoulder pain is mechanical and managed entirely in primary care. The triage task is to pull out the small number that are not: the septic joint and acute fracture/dislocation that need the same day, and the two NICE NG12 cancer pathways that shoulder pain genuinely sits on — the apical (Pancoast) lung tumour and the bony metastasis/sarcoma. Marcus's mechanical story is reassuring, but his smoking and weight loss place him in the urgent-investigation lane regardless of how typical the shoulder examination looks.

🔴 Emergency

Same day / 999

Immediate action

Septic glenohumeral jointHot, swollen, exquisitely painful joint + fever/systemic upset → acute admission; aspiration + IV antibiotics; do NOT inject
Fracture or dislocation after traumaDeformity, unable to move, or neurovascular deficit → urgent X-ray; A&E for reduction of dislocation; document axillary nerve
Referred cardiac / visceral painExertional or left shoulder-tip pain with systemic features → ECG/observations; treat as cardiac or acute abdomen as indicated

🟠 Urgent / Refer

2WW & early specialist

Days–2 weeks

Smoker + weight loss / atypical pain (?Pancoast)Urgent chest X-ray within 2 weeks — NICE NG12 lung cancer; abnormal → 2WW lung pathway
Unexplained bony pain / cancer historyUrgent X-ray — NICE NG12 bone sarcoma (48h in young people) or suspected metastases in adults
Acute cuff tear with weakness (active patient)Shoulder surgical opinion ideally within ~2 weeks for repair consideration

🟢 Routine

GP Management

Primary care first-line

Subacromial pain / rotator cuff tendinopathyAnalgesia + graded physiotherapy; consider subacromial injection; review 6 weeks
Frozen shoulder (capsular pattern)Explain natural history; analgesia; physio; intra-articular steroid in painful phase; check HbA1c
ACJ pain / glenohumeral OAAnalgesia; activity modification; physiotherapy; targeted injection; refer if persistent/severe

🎓 SCA Checkpoint — Step 2Tasks

Triage rationale

"Your shoulder itself behaves like a wear-and-tear / cuff problem, which we treat here. But the smoking and the weight loss mean I want a chest X-ray within two weeks to be safe — those two things together are exactly when guidelines say to check."

Deductions

Triaging on the shoulder examination alone and overlooking the NG12 chest X-ray trigger
Not recognising acute cuff tear with weakness as time-critical for surgery
Injecting a joint that could be septic

Step 3

Examination — Look · Feel · Move · Special Tests · Neuro & Red-Flag Signs

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The examination answers one decisive question first — is passive external rotation preserved or lost? — because that single finding separates the rotator cuff (passive range preserved) from frozen shoulder and glenohumeral OA (capsular pattern, passive external rotation lost). Then special tests localise the cuff lesion, and a neurological screen plus inspection for Horner's and hand-muscle wasting cover the sinister causes. Always compare both sides, and examine the cervical spine — the neck is the great mimic of shoulder pain.

👁️ Look · Feel

Step	What you are looking for
Inspection	Wasting of supraspinatus/infraspinatus (chronic cuff tear or suprascapular nerve), deltoid wasting (axillary nerve), a prominent ACJ step or a "Popeye" biceps bulge (long head rupture), scapular winging or dyskinesis, swelling or deformity.
Palpation	Tenderness localised over the ACJ (ACJ pathology), the greater tuberosity / subacromial space (cuff), the bicipital groove (biceps), or the glenohumeral joint line. Warmth suggests inflammation/infection.
🚩 Red-flag inspection	Ptosis + constricted pupil (Horner's), wasting of the small muscles of the hand (T1), supraclavicular lymphadenopathy — all point away from a mechanical shoulder toward an apical lung tumour or neurological cause.

🔄 Move — the decisive step

Movement	Interpretation
Active range — painful arc	Pain through mid-abduction 60–120° = subacromial impingement / cuff. Pain in the high arc 170–180° = ACJ.
Passive external rotation (elbow at side)	The pivotal test. Preserved → rotator cuff problem. Globally lost (and matched active loss) → frozen shoulder or glenohumeral OA (capsular pattern).
Active vs passive abduction	Cannot actively lift but the arm moves freely when passively supported → cuff tear (weakness), not stiffness.
Hand-behind-back (internal rotation)	"Can you reach your back pocket / between your shoulder blades?" — early and markedly restricted in frozen shoulder.

3A — Special tests (localise the lesion)

Test	How / what it isolates	Positive suggests
Empty-can (Jobe)	Arm at 90° abduction, 30° forward, thumb down; resist downward pressure. Pain/weakness isolates supraspinatus.	Supraspinatus tendinopathy / tear
Resisted external rotation	Elbow at side, 90° flexion; resist outward rotation. Weakness isolates infraspinatus / teres minor.	Infraspinatus tear
Gerber lift-off / belly-press	Hand behind back lifted off, or press belly with elbow forward. Weakness isolates subscapularis.	Subscapularis tear
Hawkins–Kennedy / Neer	Provocation of the subacromial space (internal rotation at 90° flexion / passive forward elevation). Pain = impingement.	Subacromial impingement
Drop-arm	Patient cannot lower the abducted arm smoothly / it drops. Indicates a substantial full-thickness cuff tear.	Significant cuff tear → imaging/surgery
Scarf (cross-body adduction)	Cross-body adduction loads the ACJ. Pain localised to the top of the shoulder.	ACJ pathology
Apprehension / relocation	In abduction + external rotation the patient feels the shoulder will "come out"; relieved by posterior pressure.	Anterior instability

3B — Don't forget the neck and the nerves

Examine the cervical spine (range, and whether neck movement reproduces the shoulder/arm pain) — cervical radiculopathy and referred neck pain are classic shoulder mimics. Perform a neurological screen of the arm (power, sensation, reflexes) — focal weakness/wasting (especially T1 small-hand-muscle wasting), a sensory level, or Horner's redirect you to a neurological or apical-tumour cause. A shoulder that examines normally in someone with a convincing pain story has told you the problem is not in the shoulder.

🎓 SCA Checkpoint — Step 3TasksGlobal Skills

Examination narration that scores

"I'm going to check how far the shoulder moves on its own and then how far I can move it for you — that tells me whether this is a stiff (frozen) shoulder or a cuff problem."

"I'll also have a quick look at your eye and your hand and feel your neck — I want to be thorough given everything you've told me."

Deductions

Testing only active movement and never assessing passive external rotation
No neurological/neck screen in a patient with red-flag features
Not comparing both sides

Step 4

Investigations — Often None · Targeted Imaging · The Red-Flag Tests

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Most mechanical shoulder pain needs no investigation — the diagnosis is clinical and the first-line management (analgesia + physiotherapy) does not depend on a scan. Investigations are targeted: an X-ray for trauma, suspected OA, calcific tendinopathy or a bony lesion; ultrasound for cuff tears and guided injection; MRI for surgical planning or instability; and the specific red-flag tests — a chest X-ray for the smoker with weight loss (NG12), and bloods where infection, inflammation or metastasis is in the frame. This is exactly where Marcus's request for "a scan" is reshaped: the most important scan for him is a chest X-ray, not an MRI of the shoulder.

🩻 Imaging — when and why

Test	Indication
Plain X-ray (shoulder)	Trauma, suspected glenohumeral/ACJ OA, calcific tendinopathy, suspected bony lesion, or before injection if the diagnosis is uncertain. Often normal in pure cuff disease.
Ultrasound	First-line for confirming a rotator cuff tear and assessing its size; allows image-guided subacromial/intra-articular injection.
MRI / MR arthrogram	Surgical planning for cuff tears, and assessment of labral/instability lesions in younger patients. Not first-line for typical subacromial pain.
🚩 Chest X-ray (urgent)	For Marcus. Smoker + unexplained weight loss + shoulder/arm pain → urgent CXR within 2 weeks to assess for apical lung tumour (NICE NG12).
🚩 Bone imaging	Unexplained progressive bony pain / cancer history → X-ray; NICE NG12 suspected bone sarcoma (very urgent in young people) or metastasis pathway.

🧪 Bloods — selective, not routine

Test	When
ESR / CRP	Suspected polymyalgia rheumatica (bilateral girdle pain + stiffness, age >50), inflammatory arthritis, or infection.
HbA1c	Frozen shoulder — strong diabetes association; new diagnosis is common and worsens prognosis; optimise control.
FBC	Infection (septic joint), and systemic illness / malignancy work-up.
Bone profile / calcium	Suspected bony metastasis or myeloma (with deep bone pain, cancer history, systemic features).
U&E	Before/with NSAID prescribing and as part of a systemic work-up.

💬 "Why not just an MRI of the shoulder?" — shared decision-making

"For the typical wear-and-tear/cuff pain you're describing, an MRI usually doesn't change what we'd do first — which is painkillers and physiotherapy — and it can throw up findings that are there in lots of pain-free shoulders too. We'd reach for a scan of the shoulder if the exercises don't work or if I think you've got a tear that might need an operation. The scan I do want to organise quickly is a chest X-ray, because of the smoking and the weight loss — that's the one that matters most for you right now."

🎓 SCA Checkpoint — Step 4TasksRelating to Others

Key reasoning

"The most useful scan for you isn't the shoulder MRI — it's a chest X-ray, and I'd like to get that within two weeks. We can scan the shoulder later if the physiotherapy doesn't get you there."

Deductions

Ordering a shoulder MRI reflexively while missing the indicated chest X-ray
Requesting bloods/imaging with no rationale ("data slop")
Not explaining to the patient why an MRI is not first-line — leaving him feeling dismissed

Step 5

Diagnosis — Pattern Recognition & the Masqueraders

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Shoulder diagnosis is pattern recognition built on three findings: the site/character of pain, the arc of painful movement, and — decisively — whether passive external rotation is preserved or lost. Get those three and most cases name themselves. Then consciously hold open the masqueraders — Pancoast tumour, bony metastasis, polymyalgia rheumatica and referred cardiac/neck pain — which is where Marcus's case lives until the chest X-ray is back.

Diagnosis	Discriminating features	Passive ER
Subacromial pain / rotator cuff tendinopathy	Commonest. Gradual, overhead and night pain; painful arc 60–120°; positive Hawkins/empty-can; pain-limited but range recoverable.	Preserved
Rotator cuff tear	Weakness rather than stiffness; positive drop-arm / isolated muscle weakness; may follow trauma (acute, time-critical) or be degenerative (older, gradual).	Preserved (weak)
Frozen shoulder (adhesive capsulitis)	Global stiffness; cannot reach back pocket; diabetic association; X-ray normal; passes through freezing→frozen→thawing over months–years.	Lost
Glenohumeral OA	Older patient; crepitus; capsular restriction; X-ray shows joint-space loss and osteophytes.	Lost
ACJ pathology	Pain localised to the top of the shoulder; high painful arc 170–180°; positive scarf test; point tenderness over the ACJ.	Preserved
Instability	Younger; dislocation history; apprehension in abduction/external rotation; sense the joint "slips."	Preserved

🚩 The masqueraders — shoulder pain that is not the shoulder

Pancoast / apical lung tumour: deep aching shoulder/arm pain in a smoker, ± Horner's, ± T1 hand wasting, ± weight loss — urgent CXR (NG12). Bony metastasis / myeloma: constant deep bony pain, cancer history, systemic features → imaging + bone profile. Polymyalgia rheumatica: bilateral shoulder-girdle pain and prolonged morning stiffness over 50 with raised ESR/CRP. Referred cervical / cardiac / diaphragmatic pain: a normal shoulder examination with a pain story that does not fit the shoulder. For Marcus, the working diagnosis is subacromial pain — but the diagnosis is not safe until the chest X-ray excludes a Pancoast tumour.

🎓 SCA Checkpoint — Step 5Tasks

Explaining the diagnosis in plain words

"What I think is going on is wear and irritation of the tendons that sit over the shoulder joint — very common and very treatable. The one thing I want to rule out, because you smoke and you've lost weight, is anything in the chest causing the pain — that's what the X-ray is for."

Deductions

Giving a confident benign label while ignoring the unexcluded red flag
Labelling "frozen shoulder" without having tested passive external rotation
Not considering PMR in an older patient with bilateral girdle pain

Step 6

Referral — Physiotherapy First · Surgery · and the 2WW Pathways

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For most shoulder pain the "referral" is to physiotherapy, which is the cornerstone of treatment — not to a surgeon or a scanner. Surgical referral is reserved for specific situations, and the urgent/2WW referrals are the safety backbone of the case. State the cancer thresholds precisely.

Referral	Who / when	Urgency
Physiotherapy / MSK service	First-line for subacromial pain, rotator cuff tendinopathy, frozen shoulder, ACJ pain and instability — graded, progressive exercise is the evidence-based core of management.	Routine — first-line
Shoulder surgery (orthopaedics)	Acute traumatic cuff tear with weakness (early — see below); recurrent instability; failed conservative management of subacromial pain; large/full-thickness symptomatic tears; advanced glenohumeral OA for arthroplasty.	Soon / routine by indication
Acute cuff tear — surgical opinion	Sudden tear + true weakness in an active patient: refer for surgical opinion ideally within ~2 weeks — the repair window closes as the tendon retracts.	Urgent (~2 weeks)
Rheumatology	Suspected polymyalgia rheumatica with diagnostic uncertainty, or an inflammatory arthritis pattern.	Routine / soon
🟣 Apical (Pancoast) lung tumour	Smoker + unexplained weight loss + atypical shoulder/arm pain (± Horner's, ± hand wasting): urgent chest X-ray within 2 weeks; if abnormal/suspicious → 2-week-wait lung cancer referral.	2WW · NICE NG12
🟣 Bone sarcoma / metastasis	Unexplained progressive bony shoulder pain: very urgent direct-access X-ray (within 48 hours) for suspected bone sarcoma in children & young people; suspected bony metastases in adults → urgent X-ray and appropriate cancer pathway.	2WW · NICE NG12
🔴 Septic arthritis	Hot, swollen, painful joint + systemic upset.	Same-day admission

🎓 SCA Checkpoint — Step 6Tasks

Stating the threshold precisely

"Because you smoke and you've lost weight, the guidance is clear — I should arrange a chest X-ray within two weeks, and if it shows anything we move straight to a fast-track chest clinic appointment."

Deductions

Referring straight to orthopaedics/MRI and bypassing physiotherapy for typical subacromial pain
Not naming the NG12 chest X-ray / 2WW pathway
Missing the narrow window for acute traumatic cuff-tear repair

Step 7

Management — Analgesia · Physiotherapy · Injection · Condition-Specific Plans

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The management of common shoulder pain rests on three pillars — control the pain, keep the shoulder moving, and rehabilitate with graded exercise — with corticosteroid injection as a short-term adjunct that buys a window for rehab rather than a cure. For Marcus the plan must also deliver the safety-net (chest X-ray) and a realistic route back to work.

7A — The three pillars (all-cause)

💊 Analgesia

Topical or oral NSAID (lowest effective dose, shortest course; gastroprotection if at risk) and/or paracetamol. Time analgesia to enable physiotherapy and sleep. Review GI/renal/CV risk before a course.

🏃 Activity & self-care

Keep it moving — relative rest from the aggravating overhead load, NOT immobilisation (a sling/disuse worsens stiffness, especially in frozen shoulder). Modify work tasks; pace overhead activity; address sleep position.

🤸 Physiotherapy

The cornerstone. Graded, progressive rotator-cuff and scapular-stabiliser exercise for subacromial pain; range-of-movement and stretching for frozen shoulder; stabiliser rehab for instability. Most improve without surgery.

7B — Corticosteroid injection — role and limits

Subacromial (impingement/cuff) or intra-articular (frozen shoulder, OA) corticosteroid injection gives short-term pain relief — useful to break a pain cycle, enable rehabilitation, or get a working window. It is an adjunct, not a cure: benefit is often weeks, and exercise therapy still does the underlying work. Limit repeated injections (tendon and tissue effects); warn diabetics of a transient rise in blood glucose; never inject a possibly infected joint. For Marcus, an injection alongside physiotherapy is a legitimate way to honour his goal of getting back to plastering sooner — once the shoulder diagnosis is confirmed and the chest X-ray is in hand.

7C — Condition-specific notes

🔧 By diagnosis

Condition	Specific plan
Subacromial / cuff tendinopathy	Analgesia + graded physio; subacromial injection for short-term relief; review 6 weeks; refer if no progress or weakness/large tear.
Frozen shoulder	Explain natural history (freezing→frozen→thawing, often 1–3 years); analgesia; maintain movement; physio; intra-articular steroid in the painful phase; optimise diabetes; refer if not settling (hydrodilatation, MUA, capsular release).
Glenohumeral OA	Analgesia, exercise, activity modification, intra-articular injection; arthroplasty referral if severe and function-limiting.
Instability	Physiotherapy for rotator-cuff and scapular stabilisers; surgical stabilisation if recurrent dislocation.
Calcific tendinopathy	Analgesia/NSAID; physiotherapy; ultrasound-guided barbotage if persistent and severe.

🔁 Safety-net & follow-up

Element	Plan
Red-flag safety-net	"Come back sooner if the pain becomes constant and unrelated to movement, you lose more weight, develop a cough or cough up blood, or notice any drooping eyelid, change in your hand, or new weakness."
Chest X-ray loop	Arrange CXR; agree how the result will be communicated and the plan if abnormal (fast-track chest clinic).
Review	Re-assess at ~6 weeks: response to physio/analgesia; consider injection or imaging if no progress; reassess function and work.
Return to work	Graded return tailored to plastering; load modification; realistic timeline; fit note if needed.
Lifestyle	Offer smoking-cessation support (healing, chest, and the X-ray context).

🎓 SCA Checkpoint — Step 7TasksRelating to OthersGlobal Skills

A plan that scores

"Here's the plan: painkillers to settle it and let you sleep, exercises from the physio which are what really fix it, and an injection to bring relief forward so you can get back to work — and a chest X-ray this week to be safe. We'll review in six weeks."

Deductions

Injection alone, with no physiotherapy and no explanation that it is short-term
Advising a sling / complete rest (worsens stiffness)
No safety-net for red-flag symptoms; no clear review

"Doc, my shoulder's been killing me for a couple of months and I can't work properly. I just want a scan and one of them steroid injections to sort it out so I can get back to it — can we do that today?"

Who you are

Marcus Bevan, 54, self-employed plasterer, right-handed. Right shoulder pain for 8 weeks, no single injury — it built up gradually. Worse reaching overhead (ceilings) and out to the side; wakes you at night when you roll onto it. Ibuprofen takes the edge off. You've had to turn down two jobs and you're worried about money — there's no sick pay when you don't work. You smoke roughly a pack a day, have done for years. You've lost "maybe half a stone" in the last couple of months without trying — you put it down to "not eating right since the shoulder's been bad" and you're not worried about it. You came in wanting a scan and an injection because a mate had an injection for his shoulder and it "fixed it."

Hidden concerns (reveal if explored)

Money/work (main concern): the real driver. You need to be earning. If the doctor works with that — gives a plan and a timeline — you relax. If they just say "no scan," you get frustrated.

The weight loss (only if asked directly): you genuinely haven't thought it's important. If the doctor explains calmly why they want a chest X-ray, you'll accept it — though you might say "you don't think it's anything serious, do you?" and need honest reassurance.

Smoking: slightly defensive — you've heard the lecture before. If offered help without being judged, you're open to it "one day."

Clinical details if asked

Gradual onset, no trauma; worse overhead and reaching out; night pain lying on it
More painful than stiff — you can still reach your back pocket, it just hurts at a certain point lifting the arm
No true weakness you've noticed; no pins and needles or wasting in the hand; no neck pain
Weight loss ~half a stone over ~2 months, unintentional; appetite "a bit down"
No fever; no cough you've thought about; smoker ~20 a day for ~20 years
No previous cancer; no diabetes that you know of; generally fit, on no regular medication

Reactions at key moments

On being examined: cooperative; the arc of movement hurts mid-way up; you can be moved through full range passively without much extra pain.
On the chest X-ray: "An X-ray of my chest? It's my shoulder…" → accept once it's explained as careful because of smoking + weight loss; may ask "it's not cancer, is it?"
On MRI not being first: mild pushback ("I thought I needed a scan") → satisfied if told the shoulder can be scanned later if physio doesn't work, and the chest X-ray is the one that matters now.
On physiotherapy: "Will exercises really sort it? I haven't got time to be messing about" → accept if told it's the thing that actually fixes it and the injection can help you get going.
Challenge line: "Look, I just need to get back to work — can't you just jab it and scan it and be done?"

"I haven't got time for weeks of exercises, doc — I've got bills. Can't you just give me the injection and the scan today and let me crack on?"

Resolution: Marcus leaves satisfied if the GP: (1) takes his work/money pressure seriously and commits to getting him back plastering safely; (2) examines the shoulder and reaches a sensible diagnosis (subacromial/cuff pain); (3) recognises the smoker + weight-loss red flag and arranges an urgent chest X-ray, framed sensitively; (4) explains why an MRI isn't first-line and offers it later if needed; (5) sets up physiotherapy as the core treatment with analgesia, and offers an injection as an adjunct to bring relief forward; (6) gives a clear safety-net and a 6-week review. He disengages if the red flag is missed, if he's simply refused, or if he's handed an injection with no examination, no safety-net and no plan.

🏥

Clinic Quick Reference

Shoulder Pain — Clinical Decision Framework

NICE CKS · Rotator cuff vs frozen shoulder · NG12 red flags · Physiotherapy first-line

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🚦 1 — Triage first

Shoulder pain

▼

🔴 Same-day / urgent

Hot swollen joint + fever → septic arthritis
Trauma + deformity / neurovascular deficit
Acute cuff tear + weakness (active patient)

Admit / urgent ortho

🟠 2WW · NG12

Smoker + weight loss / atypical pain → urgent CXR
Horner's / T1 hand wasting → apical tumour
Unexplained bony pain / cancer history → imaging

CXR ≤2 wk / 2WW

🟢 Routine

Subacromial / cuff pain
Frozen shoulder / OA
ACJ / instability

GP + physio

🔍 2 — Diagnose the pattern

Passive external rotation PRESERVED

Rotator cuff / subacromial pain (painful arc 60–120°, Hawkins+); cuff tear (weakness, drop-arm); ACJ (high arc, scarf+); instability (apprehension, young).

Passive external rotation LOST (capsular)

Frozen shoulder (global stiffness, diabetic, X-ray normal) or glenohumeral OA (older, crepitus, X-ray changes). Check HbA1c in frozen shoulder.

💊 3 — Manage

Three pillars: analgesia (topical/oral NSAID ± paracetamol) · keep moving (NOT a sling) · graded physiotherapy = cornerstone. Injection (subacromial or intra-articular) = short-term adjunct to enable rehab; limit repeats; warn diabetics; never inject a possibly septic joint. Frozen shoulder: natural history 1–3 yrs, intra-articular steroid in painful phase, refer if not settling. Review 6 weeks; refer to surgery for acute traumatic tears (urgent), recurrent instability, failed conservative, advanced OA.

🎓

SCA Quick Reference

Shoulder Pain — Consultation Playbook

Honour the goal · examine · exclude the red flag · physio + injection · safety-net

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🕐 The consultation arc

Open with the impact on work and the scan/injection request — align with the goal. Characterise the pain (mechanical vs rest, stiffness vs weakness). Screen the red flags out loud (weight loss, smoking, cancer, hand wasting). Examine with passive external rotation + a neuro/neck screen. Explain the likely cuff problem in plain words, and why a chest X-ray (not a shoulder MRI) is the priority scan. Plan: physio + analgesia + injection-as-adjunct + CXR + return-to-work + safety-net + review.

🎯 The three pivots that pass this case

1 · The red flag

Smoker + unintentional weight loss + shoulder pain → urgent CXR within 2 weeks (NG12). Missing this is the single biggest fail.

2 · The examination

Test passive external rotation: preserved = cuff; lost = frozen shoulder/OA. Add a neuro/neck screen for the masqueraders.

3 · The request

Reshape "scan + injection," don't refuse it: physio is the cure, injection an adjunct, the CXR is the scan that matters now.

⛔ Don't anchor on "muscular shoulder pain" in a smoker who has lost weight · Don't grant an MRI + injection without examining or safety-netting · Don't advise a sling/complete rest (worsens stiffness) · Don't inject a joint that could be septic · Physiotherapy — not surgery or scanning — is first-line for the common causes

Shoulder Pain · GP Clinical Reasoning Framework v2 · NICE CKS — Shoulder pain · NICE NG12 Suspected cancer: recognition and referral (lung cancer urgent CXR; bone sarcoma / metastases) · BESS/BOA shoulder guidance

Rotator cuff / subacromial pain is commonest — painful arc 60–120°, passive range preserved · Passive external rotation LOST = frozen shoulder or glenohumeral OA (check HbA1c) · Smoker + weight loss + shoulder pain → urgent CXR within 2 weeks (Pancoast, NG12) · Unexplained bony pain → NG12 bone sarcoma (48h X-ray in young people) / metastasis pathway · Acute traumatic cuff tear + weakness → surgical opinion within ~2 weeks · Physiotherapy is first-line; corticosteroid injection is a short-term adjunct, not a cure · Keep the shoulder moving — avoid a sling/immobilisation

Teaching clinicians why each step matters — not just what to do · Always consult current NICE CKS and NG12 guidance · Clinical judgement takes precedence over any framework

Shoulder Pain

Red Flags — exclude before labelling shoulder pain "mechanical"

💷 Income insecurity

🚭 The smoking + weight-loss conversation

💉 Managing the injection request

🛠️ Modifying the work, not just stopping it

😴 Night pain and mood

🚭 Cessation as an opportunity, not a lecture

Same day / 999

2WW & early specialist

GP Management

🚩 The masqueraders — shoulder pain that is not the shoulder

🎭 Patient actor brief — click to practise

Who you are

Hidden concerns (reveal if explored)

Clinical details if asked

Reactions at key moments