📋 Key Information Summary
- Shoulder pain is the third most common musculoskeletal presentation in Australian general practice, affecting approximately 1 in 3 adults during their lifetime.
- A systematic diagnostic approach using the "anatomic quadrant" model — dividing the shoulder into anterior, lateral, posterior, and superior zones — improves diagnostic accuracy beyond isolated special tests.
- Rotator cuff disorders (tendinopathy, partial tear, full-thickness tear) account for 60–70% of shoulder pain presentations; subacromial impingement is the most common mechanism.
- Adhesive capsulitis (frozen shoulder) has two phases — freezing (painful, 2–9 months) and frozen (stiff, 4–12 months) — and is associated with diabetes mellitus (prevalence 10–20% in diabetic populations).
- AC joint disorders (sprains, osteolysis, osteoarthritis) present with localised pain at the anterosuperior shoulder, worsened by cross-body adduction and overhead activity.
- The Neer and Hawkins–Kennedy tests are the most sensitive clinical tests for subacromial impingement; a positive Jobe test (empty can) suggests supraspinatus pathology.
- First-line management for most rotator cuff disorders is non-operative: relative rest, physiotherapy (scapular stabilisation and rotator cuff strengthening), and short-course oral NSAIDs or simple analgesia.
- Subacromial corticosteroid injection (MBS item 18360) provides short-term pain relief (4–6 weeks) for subacromial impingement and rotator cuff tendinopathy; no strong evidence supports repeated injections beyond 3 in 12 months.
- Red flags requiring urgent imaging/referral: acute traumatic tear with weakness in a patient >40 years, suspected septic arthritis (fever, shoulder erythema, inability to move), suspected malignancy (night pain, weight loss, bone swelling), or acute shoulder dislocation.
- Plain radiography (AP and lateral/scapular Y views) is the initial imaging modality for trauma and suspected calcific tendinopathy; ultrasound is preferred first-line for rotator cuff and soft-tissue assessment; MRI is reserved for surgical planning or diagnostic uncertainty.
- In Aboriginal and Torres Strait Islander populations, shoulder pain prevalence is 1.5–2 times higher; barriers include geographic remoteness, limited physiotherapy access, delayed presentation, and higher rates of manual labour occupations predisposing to rotator cuff injury.
- Diabetes mellitus screening is essential in all patients presenting with adhesive capsulitis; thyroid disease and cardiovascular risk factors should also be assessed.
Introduction & Australian Epidemiology
Shoulder pain is one of the most common musculoskeletal complaints presenting to Australian general practice. The shoulder girdle — comprising the glenohumeral joint, acromioclavicular (AC) joint, sternoclavicular joint, and scapulothoracic articulation — is the most mobile joint complex in the human body, trading stability for mobility. This inherent biomechanical trade-off renders the shoulder vulnerable to a range of degenerative, inflammatory, traumatic, and overuse conditions.
In Australia, shoulder pain affects an estimated 16–26% of adults at any given time, making it the third most common musculoskeletal presentation after low back pain and knee pain. The point prevalence in general practice is approximately 2–4% of all consultations. The annual incidence in the Australian population is estimated at 15–20 per 1,000 person-years, with a peak prevalence in the 45–64-year age group. Rotator cuff disorders account for 60–70% of all shoulder presentations, followed by adhesive capsulitis (5–10%) and AC joint pathology (5–8%).
The socioeconomic burden of shoulder pain in Australia is substantial. Shoulder conditions are the second most common cause of musculoskeletal-related workers' compensation claims and account for significant healthcare expenditure. In the 2019–2020 financial year, shoulder-related surgical procedures — including arthroscopic rotator cuff repair, subacromial decompression, and total shoulder arthroplasty — were among the top 20 orthopaedic procedures funded through the Medicare Benefits Schedule (MBS).
The Australian Institute of Health and Welfare (AIHW) reports that musculoskeletal conditions, including shoulder disorders, account for approximately 12% of total disease burden (DALYs) in Australia. Risk factors for shoulder pain include age >45 years, diabetes mellitus, smoking, repetitive overhead occupational or sporting activities, and prior shoulder injury. The prevalence of shoulder pain is disproportionately higher among Aboriginal and Torres Strait Islander peoples, manual labourers, and populations in rural and remote areas.
This guideline provides a structured, evidence-based approach to the diagnosis and management of the four most common categories of shoulder pain encountered in Australian primary care: the diagnostic model, rotator cuff disorders and impingement, adhesive capsulitis, and AC joint disorders.
Shoulder Pain Diagnostic Model
A structured diagnostic approach to shoulder pain improves accuracy and reduces the likelihood of misdiagnosis. The shoulder diagnostic model integrates the patient's history, mechanism of injury, pain pattern, physical examination findings, and — when indicated — imaging to arrive at a working diagnosis.
Anatomic Quadrant Approach
The most useful clinical framework divides the shoulder into four anatomic zones based on the predominant site of pain. This approach narrows the differential diagnosis rapidly and guides examination technique.
| Zone | Pain Location | Common Diagnoses | Key Tests |
|---|---|---|---|
| Anterior | Front of shoulder, bicipital groove | Biceps tendinopathy, subscapularis tear, anterior instability, adhesive capsulitis | Speed test, bear hug test, apprehension test |
| Lateral | Lateral deltoid, acromion region | Subacromial impingement, supraspinatus tendinopathy/tear, subacromial bursitis | Neer test, Hawkins–Kennedy, Jobe (empty can) test |
| Posterior | Posterior shoulder, infraspinatus fossa | Infraspinatus/supraspinatus tears, posterior instability, labral pathology (SLAP), scapular dyskinesis | External rotation lag sign, O'Brien test, posterior apprehension |
| Superior | Top of shoulder, AC joint region | AC joint sprain, AC osteoarthritis, distal clavicle osteolysis | Cross-body adduction test, AC shear test, Paxinos test |
History — Key Questions
- Onset and mechanism: Sudden traumatic (fall on outstretched hand, direct blow) vs. insidious onset (overuse, degenerative). Acute traumatic onset in a patient >40 years raises concern for acute rotator cuff tear.
- Pain character and radiation: Deltoid-region pain is referred from the rotator cuff in 80% of cases. True cervical radiculopathy typically radiates below the elbow and is associated with neck symptoms, paraesthesia, and neurological signs.
- Aggravating factors: Overhead activity and lying on the affected side suggest subacromial impingement; cross-body adduction suggests AC joint pathology; all movements with global restriction suggests adhesive capsulitis.
- Functional limitation: Difficulty with reaching behind back (internal rotation — frozen shoulder), overhead activities (impingement), and lifting (rotator cuff tear).
- Red flags: Night pain (unrelenting, wakes from sleep), systemic symptoms (fever, weight loss), acute swelling, history of malignancy, or neurological deficit (winged scapula — long thoracic nerve palsy).
- Past medical history: Diabetes mellitus, thyroid disease, cardiovascular disease (frozen shoulder); manual occupation or overhead sport (impingement, rotator cuff); previous shoulder surgery or instability.
Red Flags — Urgent Referral Criteria
- Acute traumatic shoulder dislocation — requires immediate reduction and post-reduction neurovascular assessment (axillary nerve).
- Suspected septic arthritis — fever, red/hot/swollen shoulder, inability to move the joint, raised inflammatory markers. Urgent aspiration and IV antibiotics required.
- Suspected malignancy — unexplained weight loss, night pain, bony swelling, age >50 with no trauma and progressive pain.
- Acute massive rotator cuff tear — acute weakness after trauma in a patient >40 years, inability to actively abduct the arm. Early surgical referral (within 6–12 weeks) improves outcomes.
- Neurovascular compromise — axillary artery injury (proximal humerus fracture), brachial plexus injury, scapula winging (long thoracic nerve palsy).
Physical Examination — Structured Approach
A systematic shoulder examination should follow the Look–Move–Feel–Test framework:
- Look: Inspect for swelling, bruising, deformity, muscle wasting (infraspinatus/supraspinatus fossa asymmetry suggests chronic rotator cuff tear), scapular position and rhythm.
- Active range of motion: Assess forward flexion, abduction, internal and external rotation. Compare with the contralateral side. Document any painful arc (pain between 60° and 120° of abduction — subacromial impingement).
- Passive range of motion: If active ROM is limited, assess passive ROM. Loss of passive ROM (especially internal rotation and forward flexion) suggests adhesive capsulitis. Normal passive ROM with painful active ROM suggests rotator cuff pathology.
- Strength testing: Test supraspinatus (Jobe test — empty can at 90° abduction, 30° forward flexion, internal rotation, resist downward pressure), infraspinatus (resisted external rotation at 0° abduction), subscapularis (bear hug test, lift-off test), biceps (Speed test — resisted forward flexion with forearm supinated).
- Special tests: Select based on the anatomic quadrant. See individual subtopic sections below.
Rotator Cuff Disorders & Impingement
Rotator cuff disorders represent a spectrum of pathology ranging from tendinopathy (reversible) through partial-thickness tears to full-thickness tears and, ultimately, rotator cuff arthropathy. Subacromial impingement — mechanical compression of the rotator cuff tendons (particularly supraspinatus) beneath the coracoacromial arch — is the most common underlying mechanism and the single most frequent diagnosis in shoulder pain presentations.
Pathophysiology
The rotator cuff comprises four muscles — supraspinatus, infraspinatus, teres minor, and subscapularis — that act as dynamic stabilisers of the glenohumeral joint. Neer's classic three-stage impingement model describes a continuum:
Stage I
Oedema & Haemorrhage
Reversible subacromial bursal inflammation and tendon oedema. Typically in patients <25 years with overuse or acute overload.
Setting: Primary care
Stage II
Fibrosis & Tendinopathy
Chronic tendon degeneration, fibrosis of the subacromial bursa, partial-thickness rotator cuff tears. Age 25–40 years typically.
Setting: Primary care ± sports medicine
Stage III
Tear & Bone Changes
Partial or full-thickness rotator cuff tears, acromial spurring, superior migration of the humeral head. Age >40 years.
Setting: Orthopaedic referral
Clinical Presentation
- Subacromial impingement: Lateral deltoid pain, worse with overhead activity and lying on the affected side. Painful arc between 60° and 120° of abduction. Positive Neer and Hawkins–Kennedy tests.
- Rotator cuff tendinopathy: Gradual onset of activity-related pain without significant weakness. Positive Jobe test with preserved (though painful) strength.
- Partial-thickness rotator cuff tear: Intermittent catching or sharp pain with overhead activity. Mild-to-moderate weakness on resisted testing. Night pain common.
- Full-thickness rotator cuff tear: Significant weakness (inability to actively abduct the arm against gravity — "pseudoparalysis" if massive). Visible muscle wasting. Positive drop-arm test. May present acutely after trauma or insidiously in the elderly.
Diagnostic Tests — Sensitivity and Specificity
| Test | Target | Technique | Sensitivity | Specificity |
|---|---|---|---|---|
| Neer test | Subacromial impingement | Passive forward flexion with scapula stabilised | 75–89% | 48–63% |
| Hawkins–Kennedy | Subacromial impingement | 90° forward flexion, internally rotate forearm downward | 79–92% | 25–56% |
| Jobe test (empty can) | Supraspinatus integrity | 90° abduction, 30° forward flexion, thumb down, resist downward pressure | 63–83% | 55–78% |
| External rotation lag sign | Infraspinatus tear | Elbow at 90°, maximally externally rotate, release — check if arm drops | 56–70% | 85–97% |
| Drop-arm test | Rotator cuff tear | Arm at 90° abduction, slowly lower — inability to control descent | 10–27% | 88–98% |
| Bear hug test | Subscapularis integrity | Hand on opposite shoulder, examiner pulls elbow away while patient resists | 60–92% | 75–92% |
No single shoulder test has sufficient accuracy to diagnose rotator cuff pathology in isolation. A combination of at least 3 tests (e.g., Neer + Hawkins–Kennedy + Jobe test) improves diagnostic certainty. Cluster testing — using multiple tests with known likelihood ratios — is recommended.
Management
First-Line: Conservative Management (All Stages I–II and Most Stage III)
- Relative rest and activity modification: Avoid provocative overhead activities; maintain shoulder mobility within pain-free range. Complete immobilisation is NOT recommended.
- Physiotherapy: Structured exercise programme (minimum 12 weeks) focusing on scapular stabilisation (lower trapezius, serratus anterior strengthening), rotator cuff loading (isometric progressing to eccentric), and postural correction. Evidence supports exercise as equivalent to surgery for most non-traumatic rotator cuff tendinopathy. Refer to an APA-accredited musculoskeletal physiotherapist.
- Oral analgesia: Paracetamol 1 g QDS PRN; ibuprofen 200–400 mg TDS with food or naproxen 250–500 mg BD with food for 2–4 weeks (if no contraindications). Short course only.
- Topical NSAIDs: Diclofenac gel (Voltaren Emulgel®) applied to the shoulder TDS — evidence supports efficacy for superficial shoulder conditions with fewer systemic adverse effects.
Second-Line: Subacromial Corticosteroid Injection
Consider subacromial corticosteroid injection if symptoms persist after 4–6 weeks of conservative management.
Methylprednisolone acetate
Depo-Medrol® · Subacromial injection
Adult dose
40–80 mg subacromial injection, single dose
Frequency
Single injection; may repeat after 6–8 weeks (maximum 3 per year)
MBS item
18360 — Injection into joint or bursa (consultant physician)
PBS status
✔ PBS General Benefit
Do NOT inject corticosteroid if there is clinical suspicion of full-thickness rotator cuff tear, infection, or fracture. Ultrasound guidance improves accuracy and is recommended for subacromial injections. Needle aspiration of calcific deposits may be performed under ultrasound guidance for symptomatic calcific tendinopathy (Milwaukee shoulder).
Pharmacotherapy — Oral Agents
Ibuprofen
Nurofen® · Brufen® · NSAID
Adult dose
200–400 mg PO TDS with food
Duration
2–4 weeks (short course)
Renal adjustment
Avoid if eGFR <30 mL/min/1.73 m²
PBS status
✔ PBS General Benefit
Naproxen
Naprosyn® · NSAID
Adult dose
250–500 mg PO BD with food
Duration
2–4 weeks
Renal adjustment
Avoid if eGFR <30 mL/min/1.73 m²
PBS status
✔ PBS General Benefit
Paracetamol
Panadol® · Analgesic
Adult dose
500–1000 mg PO QDS PRN (maximum 4 g/day)
Renal adjustment
No adjustment required; reduce dose if hepatic impairment
PBS status
✔ PBS General Benefit
Referral for Surgical Consideration
Orthopaedic referral is indicated for:
- Failed conservative management after 3–6 months with ongoing significant functional limitation.
- Acute traumatic full-thickness rotator cuff tear in a patient >40 years (surgical repair within 6–12 weeks offers best outcomes).
- Massive rotator cuff tear with pseudoparalysis.
- Recurrent shoulder instability secondary to rotator cuff deficiency.
Surgical options include arthroscopic subacromial decompression (acromioplasty), arthroscopic or open rotator cuff repair, and, for irreparable tears, superior capsular augmentation or reverse total shoulder arthroplasty (in patients >65 years with rotator cuff arthropathy).
Recent large RCTs (CSAW 2018, FIMPACT 2018) have demonstrated that arthroscopic subacromial decompression provides no clinically meaningful benefit over placebo surgery or structured physiotherapy for subacromial impingement. Reserve surgical decompression for confirmed full-thickness rotator cuff tears requiring repair.
Adhesive Capsulitis (Frozen Shoulder)
Adhesive capsulitis is a fibroinflammatory condition characterised by progressive, painful loss of both active and passive glenohumeral range of motion, predominantly affecting external rotation and forward flexion. It is a self-limiting condition that typically resolves over 1–3 years, though a subset of patients (10–15%) have persistent long-term restriction.
Epidemiology & Risk Factors
Prevalence in the general population is 2–5%, with peak incidence between ages 40 and 65 years. Women are affected 2–4 times more frequently than men. The most significant risk factor is diabetes mellitus, with a prevalence of adhesive capsulitis of 10–20% in diabetic patients (compared with 2–5% in the general population). Bilateral involvement occurs in up to 40% of patients (though rarely simultaneously).
Other risk factors include:
- Thyroid disease (hypothyroidism and hyperthyroidism)
- Cardiovascular disease and hyperlipidaemia
- Dupuytren's disease
- Prolonged shoulder immobilisation (post-fracture, post-stroke, post-cardiac surgery)
- Parkinson's disease
- HIV/AIDS
Clinical Phases (Natural History)
Phase 1
Freezing (Painful Phase)
Insidious onset of diffuse, severe shoulder pain — often worse at night. Progressive loss of range of motion. Duration: 2–9 months (mean 3 months).
Setting: Primary care — analgesia and reassurance
Phase 2
Frozen (Stiff Phase)
Pain gradually decreases but marked restriction of movement persists. Significant functional impairment with daily activities (dressing, reaching overhead). Duration: 4–12 months.
Setting: Primary care + physiotherapy
Phase 3
Thawing (Recovery Phase)
Gradual spontaneous recovery of range of motion. May have residual stiffness in 10–15%. Duration: 5–26 months.
Setting: Primary care + self-directed exercise
Total duration from onset to full recovery is typically 12–36 months (mean 18–24 months). Approximately 85–90% of patients recover full or near-full range of motion with appropriate management. Patient education about the natural history is essential for engagement and adherence to physiotherapy.
Diagnosis
Diagnosis is primarily clinical. Key features distinguishing adhesive capsulitis from rotator cuff pathology:
| Feature | Adhesive Capsulitis | Rotator Cuff Disorder |
|---|---|---|
| Range of motion | Both active AND passive ROM severely restricted | Active ROM limited, passive ROM preserved |
| Most restricted movement | External rotation (earliest and most affected) | Abduction (painful arc 60–120°) |
| Pain pattern | Constant, severe night pain in freezing phase | Activity-related pain, may have night pain |
| End-feel | Hard, leathery end-feel (capsular pattern) | Normal end-feel or pain-limited |
| X-ray | Typically normal; may show osteopenia of humeral head | Typically normal; may show acromial spurs or calcification |
Capsular pattern of restriction: External rotation > forward flexion > internal rotation (in order of greatest to least restriction). This is the hallmark of glenohumeral joint capsular pathology and distinguishes adhesive capsulitis from extracapsular causes of stiffness.
Investigations
- Plain radiographs (AP, lateral/scapular Y): Rule out fracture, osteoarthritis, and calcific tendinopathy. May show periarticular osteopenia in adhesive capsulitis.
- Ultrasound (MBS item 55800): May show thickening of the coracohumeral ligament (>3 mm) and axillary recess capsule (>4 mm), and reduced axillary recess volume. Useful for excluding rotator cuff tear.
- MRI (MBS item 63200): Reserved for diagnostic uncertainty. May show enhancement of the joint capsule and rotator interval on post-contrast sequences.
- Blood tests: Fasting glucose and HbA1c (screen for diabetes — mandatory in all adhesive capsulitis patients), TFTs (screen for thyroid dysfunction), ESR/CRP (if infection or inflammatory arthritis suspected).
Management
Phase 1 — Freezing (Painful Phase)
- Patient education and reassurance: Explain the natural history (self-limiting, 12–36 months). Set realistic expectations. Engagement with physiotherapy improves long-term outcomes.
- Analgesia: Paracetamol 1 g QDS PRN; short-course NSAIDs (ibuprofen 400 mg TDS or naproxen 500 mg BD for 2–4 weeks).
- Physiotherapy: Gentle range-of-motion exercises (pendular exercises, wall walks, pulley exercises). Avoid aggressive stretching in the painful freezing phase, which may exacerbate symptoms.
- Intra-articular corticosteroid injection: Consider early in the freezing phase (within the first 3 months) for patients with severe pain and functional limitation. Provides short-term pain relief (4–12 weeks) and may modestly accelerate recovery. Ultrasound-guided glenohumeral injection preferred.
Triamcinolone acetonide
Kenacort-A 40® · Intra-articular glenohumeral
Adult dose
20–40 mg glenohumeral intra-articular injection (ultrasound-guided)
Frequency
Single injection; may repeat once after 6–8 weeks if insufficient response
PBS status
✔ PBS General Benefit
Phase 2 — Frozen (Stiff Phase)
- Physiotherapy (intensive): Structured stretching programme focusing on external rotation, forward flexion, and internal rotation. Modalities include joint mobilisation (Maitland techniques), heat therapy, and supervised exercise. Refer to musculoskeletal physiotherapist.
- Home exercise programme: Daily stretching — pendular exercises, wall walks, cross-body adduction stretches, towel/internal rotation stretches. Patient adherence is the strongest predictor of outcome.
- Hydrodilatation (distension arthrography): Injection of saline ± corticosteroid into the glenohumeral joint to distend and rupture the capsule. May be offered by sports medicine physicians or interventional radiologists. Evidence supports modest short-term improvement over injection alone.
Phase 3 — Thawing (Recovery Phase)
- Continued self-directed stretching and strengthening exercises.
- Gradual return to full activity and sport.
- Monitor for recurrence (risk of contralateral involvement: ~40% within 5 years).
Surgical Management (Refractory Cases)
Surgery is rarely required and reserved for patients with persistent significant functional limitation beyond 12 months despite optimal conservative management. Options include manipulation under anaesthesia (MUA) and arthroscopic capsular release. These should be performed by an experienced shoulder surgeon.
Diabetes screening is mandatory. All patients with adhesive capsulitis should have fasting glucose and HbA1c checked. Diabetic patients have a more protracted course, greater stiffness, and poorer response to corticosteroid injection. Tight glycaemic control may improve outcomes, though direct evidence is limited.
AC Joint Disorders & Shoulder Examination
The acromioclavicular (AC) joint is a diarthrodial synovial joint connecting the distal clavicle to the acromion of the scapula. It is a common site of pathology in both traumatic and degenerative conditions, accounting for approximately 5–8% of shoulder pain presentations in general practice.
Anatomy & Biomechanics
The AC joint is stabilised by the AC ligaments (superior, inferior, anterior, posterior) and the coracoclavicular (CC) ligaments (conoid and trapezoid). The joint has a fibrocartilaginous disc (meniscus) that degenerates by the fourth decade. The AC joint transmits forces between the upper limb and the axial skeleton and is subject to significant stress during overhead and cross-body movements.
AC Joint Conditions
1. AC Joint Sprain (Traumatic)
AC joint injuries typically result from a direct fall onto the point of the shoulder ("point of shoulder" impact) and are classified by the Rockwood system:
| Type | Pathology | Clinical Findings | Management |
|---|---|---|---|
| I | AC ligament sprain, intact | Localised tenderness, no deformity | Conservative: sling, ice, analgesia, early mobilisation |
| II | AC ligament ruptured, CC ligament sprained | Visible step deformity, painful cross-body adduction | Conservative: sling 2–4 weeks, physiotherapy |
| III | AC and CC ligaments ruptured, 100% clavicle elevation | Prominent step deformity, piano-key sign positive | Conservative vs. surgical (debated — consult orthopaedics) |
| IV–VI | Severe displacement (posterior, inferior, superior) | Gross deformity, skin tenting possible | Surgical: open reduction and internal fixation |
2. AC Joint Osteoarthritis
Degenerative AC joint osteoarthritis is extremely common in patients over 40 years and is often an incidental finding on shoulder radiographs. Symptomatic AC joint OA presents with:
- Localised pain at the top of the shoulder, worse with cross-body adduction and overhead activity.
- Point tenderness directly over the AC joint.
- Positive cross-body adduction test (sensitivity 77%, specificity 79% for AC joint pathology).
- Positive Paxinos test (compression of the AC joint by thumb and index finger — sensitivity 79%, specificity 50%).
3. Distal Clavicle Osteolysis
A stress-related resorption of the distal clavicle seen in weightlifters (repeated bench press and overhead press) and manual labourers. Presents with insidious AC joint pain aggravated by activity. X-ray shows subcortical lucency, cystic changes, and irregularity of the distal clavicle.
AC Joint Examination
Focused AC joint examination should include:
- Inspection: Compare both sides. A visible step deformity (prominent distal clavicle relative to acromion) suggests AC joint separation.
- Palpation: Direct tenderness over the AC joint (located at the most superior point of the shoulder). Compare with the contralateral side.
- Cross-body adduction test: Passively bring the affected arm across the body (horizontal adduction) with the elbow extended. Pain localising to the AC joint is a positive test.
- AC shear test: Place one hand on the clavicle and one on the acromion, compressing together. Pain at the AC joint is positive.
- Piano-key sign: Press down on the elevated distal clavicle; it depresses and springs back like a piano key (Type III AC joint injury and above).
- O'Brien test (active compression test): Arm at 90° forward flexion, 10° adduction, thumb pointing down. Resist downward pressure. Repeat with palm up. Pain with the first position that improves with the second may indicate either AC joint pathology or SLAP labral lesion. If pain is localised superiorly → AC joint; if deep in the shoulder → labral.
Imaging for AC Joint Pathology
- Plain radiographs: AP shoulder (may underestimate AC joint pathology) and Zanca view (AP with 10–15° cephalic tilt — best for visualising the AC joint). Bilateral AP with weights (10 kg in each hand) for suspected Type III injuries to assess CC distance (normal <13 mm, or >50% increase from contralateral side).
- Ultrasound: Useful for dynamic assessment of AC joint stability and detecting joint effusion, capsular thickening, and distal clavicle osteolysis.
- MRI: Not usually required. Useful for evaluating associated rotator cuff or labral pathology, or suspected distal clavicle osteolysis.
- Diagnostic injection: Ultrasound-guided AC joint injection with 1–2 mL of 1% lidocaine (lignocaine). Complete resolution of pain confirms the AC joint as the pain source. MBS item 18360.
Management of AC Joint Conditions
AC Joint Sprains (Types I–II)
- Arm sling for comfort (1–2 weeks for Type I, 2–4 weeks for Type II).
- Ice 15–20 minutes every 2–3 hours for the first 48–72 hours.
- Analgesia: Paracetamol ± short-course NSAIDs.
- Early range-of-motion exercises as pain allows (within 1–2 weeks).
- Progressive strengthening from 4–6 weeks.
- Return to sport: 2–4 weeks (Type I), 6–8 weeks (Type II).
AC Joint Osteoarthritis
- Activity modification: avoid provoking overhead and cross-body activities.
- Oral analgesia: paracetamol, topical NSAIDs (diclofenac gel TDS), short-course oral NSAIDs.
- Ultrasound-guided AC joint corticosteroid injection (triamcinolone 20 mg or methylprednisolone 20–40 mg) for refractory pain. May provide relief for 3–6 months.
- Referral for distal clavicle excision (arthroscopic or open Mumford procedure) for refractory cases after 6+ months of conservative management.
Investigations
Investigation of shoulder pain should be guided by clinical findings. Most shoulder conditions can be diagnosed clinically, and imaging should be reserved for cases where it will change management.
Essential
Plain radiography (AP + lateral/scapular Y ± Zanca view)
MBS item 57700 (shoulder, 2 views). Initial imaging for all traumatic presentations, suspected fracture, dislocation, calcific tendinopathy, and to assess for glenohumeral osteoarthritis. Available in all Australian general practices and emergency departments.
Available
Musculoskeletal ultrasound (shoulder)
MBS item 55800. First-line imaging for rotator cuff tears, bursitis, tendinopathy, and AC joint pathology. Highly operator-dependent — should be performed by a sonographer with musculoskeletal experience. Increasingly available in GP practices with ultrasound capability.
Referral
MRI shoulder
MBS item 63200. Reserved for diagnostic uncertainty, surgical planning (full-thickness rotator cuff tear characterisation), suspected labral pathology, adhesive capsulitis confirmation, or when ultrasound is inconclusive. Typically requires referral to a specialist or radiology centre.
Referral
CT shoulder
MBS item 56000. For complex proximal humerus fractures, glenoid bone loss assessment in recurrent instability, and surgical planning. Requires specialist referral.
Available
Fasting glucose, HbA1c, TFTs, ESR/CRP
Mandatory in adhesive capsulitis (screen for diabetes and thyroid disease). ESR/CRP if inflammatory arthritis or infection suspected. FBC if malignancy suspected.
MBS access note: MRI of the shoulder (MBS item 63200) requires a request from a specialist or consultant physician for Medicare eligibility, unless performed in a public hospital setting. GP-requested MRI is not generally rebatable for shoulder conditions under the current MBS schedule. Discuss referral pathways with the patient's specialist.
Risk Stratification & When to Refer
Low Risk
Manage in Primary Care
Subacromial impingement, rotator cuff tendinopathy (non-traumatic), mild AC joint sprain (Type I), early adhesive capsulitis (freezing phase). Age <40, no red flags, no trauma.
Setting: GP + physiotherapy
Moderate Risk
Consider Specialist Review
Partial-thickness rotator cuff tear with functional limitation, Type II AC joint sprain, adhesive capsulitis unresponsive to 3 months of physiotherapy, suspected calcific tendinopathy.
Setting: Sports medicine or orthopaedic review
High Risk
Urgent Specialist Referral
Acute traumatic full-thickness rotator cuff tear (>40 years), Type III+ AC joint injury, suspected septic arthritis, suspected malignancy, acute shoulder dislocation, neurovascular compromise.
Setting: Orthopaedic/ED
Special Populations
Pregnancy
NSAIDs Avoid from 28 weeks gestation (risk of premature closure of ductus arteriosus, oligohydramnios). Paracetamol is preferred analgesic.
Corticosteroid injection May be used with caution in the second and third trimester for severe symptoms — discuss risks/benefits with patient and obstetric team.
Physiotherapy Safe and first-line. Modify exercises for pregnancy-related joint laxity. Avoid supine positioning after 20 weeks.
Hormonal joint laxity in pregnancy may predispose to shoulder instability and subluxation events.
Paediatrics
Shoulder pain in children Uncommon. Consider apophyseal avulsion injuries (proximal humerus), osteochondritis dissecans, or referred pain from the cervical spine.
Adolescent athletes Overhead sport athletes (swimming, tennis, throwing) may develop Little Leaguer's shoulder (proximal humeral epiphysitis). Management: rest from provocative activity, graduated return.
NSAIDs Ibuprofen 5–10 mg/kg PO TDS (maximum 30 mg/kg/day or 2.4 g/day). Use lowest effective dose for shortest duration.
Atraumatic shoulder pain in children warrants investigation to exclude malignancy (primary bone tumour) or infection.
Elderly (≥65 years)
Rotator cuff tears Degenerative full-thickness tears are common (prevalence >50% in asymptomatic patients over 60). Symptomatic management prioritised over surgical repair in most cases.
NSAIDs Use with extreme caution. Increased risk of GI bleeding, renal impairment, cardiovascular events. Prefer topical NSAIDs or paracetamol. If oral NSAIDs required, co-prescribe PPI (omeprazole 20 mg daily).
Corticosteroid injection Safe but monitor blood glucose in diabetic patients (may elevate BSL for 48–72 hours).
Proximal humerus fracture Low-energy fractures in the elderly are typically managed conservatively (sling, early mobilisation). Refer for displaced fractures (Neer 3- or 4-part).
Fall prevention strategies should be discussed in all elderly patients presenting with traumatic shoulder injury.
Renal Impairment
NSAIDs Avoid if eGFR <30 mL/min/1.73 m². If eGFR 30–60, use lowest dose for shortest duration and monitor renal function.
Paracetamol Safe at standard doses; no renal adjustment required.
Dialysis patients Shoulder pain in dialysis patients may indicate amyloid arthropathy (β2-microglobulin deposits), rotator cuff tears (increased prevalence), or calcific periartthritis. Refer to nephrology for co-management.
Corticosteroid injection is safe in renal impairment but consider reduced cortisol clearance.
Hepatic Impairment
Paracetamol Maximum 2 g/day in chronic liver disease (Child–Pugh A–C). Safe at reduced doses.
NSAIDs Avoid in cirrhosis (increased risk of GI bleeding, hepatorenal syndrome). Prefer paracetamol or topical NSAIDs.
Corticosteroid injection Use with caution in hepatic impairment; monitor for hyperglycaemia and adrenal suppression.
Patients on anticoagulants (common in liver disease) should have coagulation checked prior to corticosteroid injection.
Immunocompromised
Infection risk Lower threshold for investigating suspected septic arthritis in immunocompromised patients (diabetes, HIV, biologics, transplant recipients). Unusual organisms (e.g., P. jirovecii, Mycobacterium) may be responsible.
Corticosteroid injection Use with caution. Consider deferring in patients with active systemic infection or severely immunocompromised state (absolute CD4 <200 cells/μL in HIV).
Adhesive capsulitis More common in HIV-positive patients. Screen for concurrent opportunistic infection if shoulder is acutely hot and swollen.
Post-injection infection risk is low but counsel immunocompromised patients to present promptly if increasing pain, redness, or fever develops after injection.
Aboriginal and Torres Strait Islander Health Considerations
Aboriginal and Torres Strait Islander Health
Quick Reference — Common Shoulder Presentations
Subacromial impingement
Physiotherapy + NSAIDs (± subacromial corticosteroid injection)
6–12 weeks conservative
Painful arc 60–120°, positive Neer/Hawkins
Rotator cuff tendinopathy
Eccentric loading programme + oral/topical NSAIDs
12 weeks minimum
Jobe test positive with preserved strength
Adhesive capsulitis
Physiotherapy + analgesia (± glenohumeral corticosteroid injection)
12–36 months natural history
Loss of both active and passive ROM; screen for diabetes
AC joint sprain (Type I–II)
Sling + ice + analgesia + early mobilisation
2–6 weeks
Localised superior pain, positive cross-body adduction
AC joint osteoarthritis
Topical NSAIDs ± AC joint corticosteroid injection
Ongoing management
Point tenderness AC joint, worse with cross-body adduction
Calcific tendinopathy
Physiotherapy + NSAIDs; US-guided barbotage if refractory
6–12 weeks
X-ray shows calcific deposit; acute phase may mimic septic arthritis
📚 References
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