Red flags when assessing the shoulder joint

Red flags when assessing the shoulder joint

Refer to Emergency Department if you suspect fracture, dislocation, or infection.

Acute severe shoulder pain needs proper and competent diagnosis. Any shoulder "red flags" identified during primary care assessment needs urgent secondary care referral (1):

• suspected infected joint needs same day urgent referral
  • suspect an infected joint if it is hot, red, swollen, or acutely painful, possibly with systemic signs of sepsis
  • swelling and effusion can be difficult to detect in the shoulder, so have a low threshold for referral (2)
    
    
• unreduced dislocation needs same day urgent referral
  
  
• suspected malignancy or tumour needs urgent referral following the local 2-week cancer referral pathway
  • consider in a patient with a new, unexplained soft tissue mass or swelling, particularly if they have a history of cancer
  • will need urgent referral (to be seen within two weeks) following the local cancer referral pathway
    
    
• an acute cuff tear as a result of a traumatic event needs urgent referral and ideally should be seen in the next available outpatient clinic
  
  
• suspected inflammatory oligo or poly-arthritis or systemic inflammatory disease should be considered as a 'rheumatological red flag' and local rheumatology referral pathways should be followed
  
  
• neurological injury or pathology (2)
  • patient presents with sudden serious motor or sensory deficit of the arm
  • patient needs same day emergency referral

Reference:

• Rangan A, Goodchild L, Gibson J, et al. Frozen Shoulder [published correction appears in Shoulder Elbow. 2016 Jul;8(3):215]. Shoulder Elbow. 2015;7(4):299-307. doi:10.1177/1758573215601779
• Murphy R J, Bintcliffe F. Ask the expert: assessment of shoulder pain in primary care BMJ 2023; 382 :p1255 doi:10.1136/bmj.p1255