Reasoning GP · Algorithm · 1-page summary
Shoulder pain in adults
For: adults with acute or chronic shoulder pain in primary care. Not for: children (use local paediatric pathways) or major trauma (A&E). Known PMR or GCA: see the polymyalgia rheumatica and GCA protocols.
Core rule: rule out referred and emergency causes before calling it musculoskeletal. Always examine the neck, and think heart, chest and abdomen when the shoulder examination is normal.
0Stop — call 999 now — do not delay transfer for an ECG
- Shoulder pain + chest discomfort, breathlessness, sweating, nausea, jaw or arm pain, syncope or exertional symptoms (possible ACS) → 999 if ongoing or in the last 12 h; 12–72 h ago → Same-day hospital (CG95).
- Shoulder-tip pain + hypotension, collapse or shock, especially after trauma or surgery or if pregnancy is possible (bleeding spleen, ectopic) → 999
- Dislocation with vascular compromise, or septic arthritis with haemodynamic instability → 999
1Triage — active vs passive range
| Pattern | Points to |
|---|---|
| Painful arc | Rotator-cuff-related pain or cuff tear |
| Active and passive lost | Frozen shoulder (external rotation first), GH OA, fracture, dislocation or septic arthritis |
| Active lost, passive kept | Cuff tear, pain inhibition or neurological cause |
| Full, painless range | Referred: neck, heart, chest or abdomen |
2Screen — one row is enough
- Septic arthritis: severe pain, marked loss of passive movement, fever or systemic illness, even if not hot or swollen → Same-day ED / orthopaedics. No injection until infection is excluded.
- Trauma, cannot move the shoulder: → Same-day ED. No external rotation = posterior dislocation until X-rayed. Check the axillary nerve.
- GCA (≥50, new headache, scalp tenderness, jaw or tongue claudication, visual symptoms): start glucocorticoids promptly if suspicion is significant → Same-day fast-track referral; visual symptoms → same-day ophthalmology.
- Arm neurological deficit or Horner's (Pancoast) → Urgent CXR / lung referral. Myelopathy → Urgent MRI; known cancer → MSCC pathway.
- Weight loss, night sweats, past cancer, a mass, or rest or night pain with no mechanism → Urgent imaging and targeted bloods; NG12 pathways. Do not wait.
- Aged 40+, 2 or more unexplained lung symptoms, or ever smoked and 1 → CXR within 2 weeks (NG12)
3Assess — only once blocks 0–2 are answered
☐ Wasting, winging ☐ Active and passive range ☐ Cuff strength, drop arm, lag signs ☐ ACJ (scarf test) ☐ Apprehension ☐ Neck, always ☐ Axillary nerve, Horner's, nodes
X-ray (two planes) for trauma, OA, calcific or bone lesions, and before confirming frozen shoulder (BESS/BOA). USS or MRI only for a suspected cuff tear if it changes management. Bloods only if infection, inflammation, PMR or cancer is suspected.
4Classify — only if the screen is negative
- Rotator-cuff-related pain — painful arc, pain on resisted testing, passive range normal → physiotherapy.
- Cuff tear — weakness, lag signs, drop arm; passive range kept. Degenerative → rehabilitation first.
- Frozen shoulder — active and passive loss, external rotation first; ask about diabetes and thyroid.
- ACJ or GH OA — ACJ tenderness, painful cross-body adduction; GH OA: global restriction, crepitus.
- Neck or PMR — dermatomal symptoms, full shoulder range → cervical radiculopathy (NG127). Bilateral girdle pain and stiffness, ≥50, raised markers → PMR; assess for GCA.
- Uncertain or not settling — say so; review the diagnosis and reconsider referred and sinister causes.
5Treat today — only these
- Analgesia: paracetamol; topical NSAID; oral NSAID at the lowest dose for the shortest time, PPI where appropriate. Caution: CKD, CVD, GI bleed, anticoagulants, pregnancy, older age. Doses: NICE/SPC, BNF, local formulary.
- Keep moving: modify activity, no complete rest; home exercises; physiotherapy.
- Steroid injection (subacromial for cuff pain; intra-articular early in frozen shoulder): adjunct to physio, benefit weeks. Not if infection possible; warn about glucose in diabetes.
- Typical PMR: prednisolone 15 mg daily once mimics are excluded and GCA assessed; consider bone protection.
6Refer
- Acute traumatic cuff tear (acute loss of elevation, objective weakness) or recurrent dislocation → Urgent next available shoulder clinic.
- Degenerative tear, frozen shoulder or calcific tendinopathy not settling with rehabilitation → MSK / orthopaedics. GH OA affecting quality of life despite non-surgical care → joint replacement opinion (NG226; not on age or BMI).
- Inflammatory arthritis; PMR that is atypical, refractory, relapsing or uncertain → rheumatology.
7Never reassure by
- A normal shoulder examination: the pain may be referred.
- A joint that is not hot or swollen: the glenohumeral joint is deep.
- Stiffness after trauma: no external rotation is a posterior dislocation until X-rayed.
- A normal CXR when Pancoast is still suspected.
- A good response to steroid: it supports PMR but does not prove it.
- "Frozen shoulder" or "cuff" when it fails to improve: re-evaluate, including for malignancy.
8Safety-net — say it, then document it
999 “Call 999 for chest pain, sweating, jaw pain or sudden breathlessness with the shoulder pain; fainting or collapse with shoulder-tip or tummy pain; a cold, pale arm; or sudden loss of vision with headache or jaw pain.”
Same day: “Fever or feeling unwell with severe pain and loss of movement, new or worsening weakness or numbness in the arm, severe uncontrolled pain, a drooping eyelid, or any change in vision — contact us today.” Come back promptly: “weight loss, night sweats or pain worse at rest.”
✓Safe to leave primary care only if — all five, documented
No block 0–2 row applies
Neck examined; active and passive range recorded
One pattern explains the pain, or uncertainty stated
Exercise or physio plan; review owner and date set
Safety-net given and documented
Summary of the full Reasoning GP shoulder pain algorithm, which holds the detail and evidence. Sources: NICE NG12 (updated April 2026), CG95, NG126, NG226, NG127, NG234; BSR GCA guideline 2020; BSR/BHPR PMR guideline 2009; BESS/BOA pathways. Clinical reference — follow local pathways and check doses: NICE/SPC, BNF.