CCGI Best Practice Collaborators
CCGI Best Practice Collaborators
CCGI Best Practice Collaborators
In April 2016, CCGI Opinion Leaders were joined by a new team of CCGI Best Practice Collaborators. These are influential evidence-informed clinicians recently nominated by their colleagues in a nationwide survey. They are assisting Opinion Leaders in their area with reaching out to other chiropractors and teaching them about critical thinking, proper interpretation of evidence-informed clinical practice guidelines, and evidence-informed practice in general.
CCGI is delighted to have them on board and looks forward to collaborating with them to take the best practices forward in Canada.
Roles and Activities of CCGI Best Practice Collaborators
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understanding how clinical practice guidelines are developed;
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discussing best practices and guidelines with colleagues;
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having a presence on social media to raise awareness of resources on evidence-informed practice;
-
encouraging clinicians and patients to use the CCGI website and resources;
-
making presentations on evidence-informed practice at continuing education events and conferences in collaboration with their local opinion leaders team.
In April 2016, CCGI Opinion Leaders were joined by a new team of CCGI Best Practice Collaborators. These are influential evidence-informed clinicians recently nominated by their colleagues in a nationwide survey. They are assisting Opinion Leaders in their area with reaching out to other chiropractors and teaching them about critical thinking, proper interpretation of evidence-informed clinical practice guidelines, and evidence-informed practice in general.
CCGI is delighted to have them on board and looks forward to collaborating with them to take the best practices forward in Canada.
Roles and Activities of CCGI Best Practice Collaborators
-
understanding how clinical practice guidelines are developed;
-
discussing best practices and guidelines with colleagues;
-
having a presence on social media to raise awareness of resources on evidence-informed practice;
-
encouraging clinicians and patients to use the CCGI website and resources;
-
making presentations on evidence-informed practice at continuing education events and conferences in collaboration with their local opinion leaders team.
In April 2016, CCGI Opinion Leaders were joined by a new team of CCGI Best Practice Collaborators. These are influential evidence-informed clinicians recently nominated by their colleagues in a nationwide survey. They are assisting Opinion Leaders in their area with reaching out to other chiropractors and teaching them about critical thinking, proper interpretation of evidence-informed clinical practice guidelines, and evidence-informed practice in general.
CCGI is delighted to have them on board and looks forward to collaborating with them to take the best practices forward in Canada.
Roles and Activities of CCGI Best Practice Collaborators
-
understanding how clinical practice guidelines are developed;
-
discussing best practices and guidelines with colleagues;
-
having a presence on social media to raise awareness of resources on evidence-informed practice;
-
encouraging clinicians and patients to use the CCGI website and resources;
-
making presentations on evidence-informed practice at continuing education events and conferences in collaboration with their local opinion leaders team.
Are you interested in getting involved with CCGI?
We are always looking to get people involved in our projects. No experience necessary - we provide training!
Contact us today!
Are you interested in getting involved with CCGI?
We are always looking to get people involved in our projects. No experience necessary - we provide training!
Contact us today!
Soft Tissue Shoulder Disorders Care Pathway
Date of last update: May 2025
About Soft Tissue Shoulder Disorders
Overview: Shoulder pain is a common condition that can be acute or persistent, presenting as pain, discomfort and limited function in the shoulder area. The majority of shoulder pain cases stem from soft tissue disorders such as rotator cuff tendinopathy, bursitis, and adhesive capsulitis, which share similar mechanisms, clinical symptoms, and signs in a primary care setting. However, shoulder pain can also result from serious underlying pathologies requiring medical attention, such as fractures, infections, or systemic conditions like rheumatoid arthritis.
Effective Management: Effective management of shoulder pain typically involves conservative care that considers physical, psychological, social, and environmental elements. Treatment plans are based on clinical signs and symptoms, patient preferences, and the individual’s context, as there is no one-size-fits-all approach. Managing shoulder pain necessitates a comprehensive and individualized strategy. Ethical, evidence-driven, transparent, flexible, and responsive care is necessary. Essential interventions include education, reassurance, addressing psychosocial factors, maintaining daily activities, and self-care practices. Additional interventions are selected through shared decision-making, aiming to optimize function and participation. Continuous monitoring and assessment of outcomes ensure alignment with patient goals. Effective management can also occur through virtual or hybrid care.
About the Care Pathway
Purpose: This pathway offers structured, evidence-based guidance for providers delivering conservative care, outlining key steps of the clinical encounter. It also supports referral and co-management decisions for providers not directly providing such care.
Development: This pathway draws on current best practices synthesized from clinical guidelines when available, and from systematic reviews when guidelines are lacking. Content is reviewed periodically to reflect emerging evidence and to ensure continued relevance. Where evidence is evolving or mixed, guidance is informed by the most robust available sources. Input from clinicians, educators, and researchers facilitates alignment with real-world needs and encourages ongoing improvement.
Disclaimer:
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This care pathway is intended to support, not replace, clinical decision-making or advice from a qualified healthcare provider. It offers practice guidance by presenting evidence-informed recommendations in a simplified and user-friendly format. Terminology used throughout is intended to aid understanding and application in clinical settings and should not be interpreted as formal diagnostic or billing terminology. This document is not authoritative, prescriptive, or regulatory.
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Providers are expected to use their professional judgment and consult authoritative sources such as regulatory standards and policies, diagnostic classification systems like ICD-10-CA, scope-of-practice documents, continuing professional education materials, and peer-reviewed literature. While this content is periodically reviewed to reflect current evidence, it is not definitive and may not apply to all clinical scenarios.
1. Record Keeping
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Document all findings and recommendations on an ongoing basis, including SOAP notes at each visit (subjective, objective, assessment, plan).
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Adhere to jurisdictional standards.
2. Informed Consent
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Document verbal consent for health history taking, physical examination, contact in sensitive areas.
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Obtain written consent for treatment.
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Adhere to jurisdictional standards.
3. Health History
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Apply cultural awareness and trauma-informed care principles.
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Sociodemographic: Age, gender, sex.
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Main complaint: Location, onset, duration, radiation, frequency, intensity, character, aggravating/relieving factors, associated symptoms.
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Body systems: Neurologic, cardiovascular, genitourinary, gastrointestinal, muscles and joints, eyes/ears/nose/throat, respiratory, skin, mental health, reproductive.
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Health, lifestyle, family, social, and occupational history: Past medical conditions, medications (including opioids), injuries, hospitalizations, surgeries, diet, exercise, sleep habits, smoking, alcohol/substance use, family support, caregiver responsibilities, work/school environment.
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Social determinants of health: Employment, childcare, education, nutrition, housing, domestic violence, child maltreatment, discrimination, isolation.
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Previous treatments and responses: Effectiveness and any adverse events.
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Beliefs and expectations: Understanding of their condition, treatment expectations.
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Red, yellow, and orange flags (sections 4 – 6).
Meaningful Outcomes:
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Pain: Pain scales (e.g., NRS), pain diagram.
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Function and Participation: Impact of shoulder pain on daily activities (SPADI, DASH, QuickDASH, PSFS, WHODAS, MYMOP, MYMOP Follow-up).
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Recovery: Self-rated recovery scales.
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Quality of Life: SF-12.
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Work Status: Return to work/school/activities.
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Individual Goals: SMART goal setting: Specific, Measurable, Achievable, Relevant, Timely.
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Patient Feedback: Experience and satisfaction with care.
4. Differential Diagnosis Requiring Medical Attention
ACTION: Refer to emergency care immediately for red flags:
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Shoulder Infection: Immunosuppression, recent infection or surgery, TB (tuberculosis) history, unexplained fever/chills, IV drug use, poor living conditions.
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Traumatic Shoulder Fracture: Severe trauma.
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Acute Neurological Deficit (e.g., brachial plexus injury, acute cervical radiculopathy): Significant sensory/motor deficits in the upper extremity.
ACTION: Refer to appropriate medical provider:
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Shoulder Malignancy: Progressive pain, history of cancer, constitutional symptoms (fatigue, weight loss, night pain).
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Inflammatory Arthritides (e.g., polymyalgia rheumatica, rheumatoid arthritis, systemic lupus erythematosus): Morning stiffness >1 hour, systemic symptoms (fatigue, weight loss, fever), symmetrical joint pain, joint swelling and deformity, skin lesions.
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Referred Pain (from visceral conditions): Chest pain, shortness of breath, nausea (cardiac); shortness of breath, cough, pleuritic pain (pulmonary); epigastric pain, heartburn, post-meal pain (gastrointestinal); pain with deep breathing/coughing, hiccups (diaphragmatic).
6. Psychosocial Factors (Yellow Flags)
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Factors that may delay recovery: Fear of movement, poor recovery expectations, depression, anxiety, reduced activity, over-reliance on passive treatments, lack of social support, work-related issues, family issues, litigation or compensation claims; maladaptive coping mechanisms.
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Action: Address these as part of conservative care, co-manage, or refer to an appropriate provider.
7. Physical Examination
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Observation: Abnormalities, asymmetries, posture, gait, movements, facial expression.
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Range of Motion: Active, passive, resisted (flexion, extension, abduction, adduction, internal and external rotation).
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Palpation: Bone, joint, and muscle for tenderness, swelling, muscle tightness, or temperature changes.
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Neurological Examination: Motor strength, reflex, sensory testing (C4, C5, T1, T2); upper and lower motor neuron signs.
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Special/Orthopedic Tests: Select as appropriate based on clinical judgment.
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Advanced Diagnostics: Radiography is not routinely recommended in the absence of red flags or other specific individual factors (e.g., potential contraindications to treatment). Consider ultrasound or MRI if there is non-response to treatment (e.g., to differentiate between full- and partial-thickness rotator cuff tears).
8. Clinical Presentation for Soft Tissue Shoulder Disorders
Includes rotator cuff conditions (e.g., tendinopathies, partial tears), impingement syndrome, bursitis, calcific tendinitis, biceps tendon conditions, shoulder instability, AC joint conditions, labral tears and SLAP lesions, adhesive capsulitis, myofascial pain syndrome, osteoarthritis.
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Pain: Localized shoulder area with or without referred pain.
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Signs/Symptoms: Sharp, dull, shooting, or aching pain; aggravated by specific movements; may refer into the arm.
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Exam: Pain reproduced by tests; typically, no neurological deficits.
9. Treatment Considerations for Soft Tissue Shoulder Disorders
After providing a report of findings and obtaining written informed consent.
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Core Interventions:
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Education and reassurance: Provide clear information that most soft-tissue shoulder disorders are self-limiting and do not require invasive treatments.
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Address yellow flags (psychosocial factors): Incorporate strategies such as education, mindfulness, meditation, CBT, or referral to mitigate fear-avoidance behaviours, stress, or anxiety, which may delay recovery.
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Maintain activities of daily living: Encourage continued movement and activity to prevent deconditioning, avoiding prolonged rest or immobilization, which can lead to stiffness.
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Self-care: Promote home-based exercise, balanced nutrition, good sleep hygiene, stress management, maintaining a healthy body weight, and avoiding smoking/substance abuse.
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Engage in social and work activities: Encourage social and work activities as part of the rehabilitation process.
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Interventions for Shoulder Pain (Any Duration):
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Exercise therapy:
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Acute/subacute (≤ 3 months): Gentle range of motion (ROM) and mobility exercises, alongside light strengthening (e.g., isometric exercises).
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Chronic (> 3 months): Progress to stretching, strengthening, and scapular stabilization exercises.
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Cervicothoracic/thoracic spine manipulation: For shoulder pain associated with restricted movement or pain in the cervicothoracic spine.
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Low-level laser therapy
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Multimodal care: Heat/cold therapy, joint mobilization, and ROM exercises.
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Medications: Consult with a medical provider. Short-term use analgesics or NSAIDs can be considered after non-pharmacological treatments. Long-term use and opioids should be avoided.
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Corticosteroid injections: For severe pain or functional limitations; for conditions like rotator cuff tendinopathy, adhesive capsulitis, or bursitis. Use short-term, with caution regarding long-term risks.
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Additional Considerations for Chronic Shoulder Pain (>3 months):
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Laser acupuncture: If conventional treatments have not provided adequate relief.
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Shockwave therapy: For calcific tendinitis based on imaging findings.
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Therapeutic ultrasound: Consider for calcific tendinitis.
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General physician care: Provide information, advice, and pharmacological pain management when necessary.
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10. Prognosis
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Recovery: Soft tissue shoulder disorders are most commonly benign and self-limited, but can recur or persist.
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Negative Prognostic Factors: Longer duration of symptoms, higher severity and complex types of injuries (e.g., full-thickness rotator cuff tears, labral tears, shoulder dislocations, severe osteoarthritis), older age, lower activity level and physical fitness, poor initial response to treatment, mental health issues, poor recovery expectations, work-related factors, previous shoulder injuries.
11. Ongoing Follow-up
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Continuously realign treatment plan with patient’s evolving goals, feedback, outcomes, and clinical judgment.
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Consider referral or co-management if no improvement within established timeline for treatment (e.g., 6-8 weeks).
12. Criteria for Discharge
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Establish clear criteria for discharge (e.g., achieving initial goals, reaching a plateau, progressing signs and symptoms).
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Discuss post-discharge plans, including self-management strategies and potential follow-ups.
References
Lowry V, et al. A systematic review of clinical practice guidelines on the diagnosis and management of various shoulder disorders. Arch Phys Med Rehabil, 2024.
Yu, H. et al. Noninvasive management of soft tissue disorders of the shoulder: A clinical practice guideline from the Ontario Protocol for Traffic Injury Management (OPTIMa) collaboration. European Journal of Pain, 2021.
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