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Soft Tissue Shoulder Disorders Care Pathway

Date of last update: September, 2024

About Soft Tissue Shoulder Disorders

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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.

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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.

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About the Care Pathway

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  • Principles: Based on recommendations drawn from established clinical guidelines, integrating the best available evidence, clinical expertise, and patient preferences. Treatments are aligned with current guideline-supported practices. Developed with input from professional leaders, clinicians, and researchers.

 

  • Target Audience: Supports clinicians who deliver conservative care, and informs those who do not but may see people with these conditions for referral or co-management. Provides essential, concise guidance on key steps of a clinical encounter, with access to detailed information by clicking on specific sections. Includes a downloadable one-page quick guide for quick access to key information.

 

  • Updates: Regular updates are communicated through social media to ensure users have current information. The care pathways are 'living' documents, reflecting the state of clinical practice and research evidence to our best knowledge at the time of development. They may be updated to ensure they remain current and evidence driven.

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  • ​Disclaimer: This care pathway is not intended to replace advice from a qualified healthcare provider.

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***CLICK HERE FOR A ONE-PAGE QUICK GUIDE: Soft Tissue Shoulder Disorders Quick Guide

1. Record Keeping

  • Document all findings and recommendations on an ongoing basis, including SOAP notes at each visit (subjective, objective, assessment, plan).

  • Adhere to jurisdictional standards.

2. Informed Consent

  • Document verbal consent for health history taking, physical examination, contact in sensitive areas.

  • Obtain written consent for treatment.

  • Adhere to jurisdictional standards.

3. Health History

  • ​Apply cultural awareness and trauma-informed care principles.

  • Sociodemographic: Age, gender, sex.

  • Main complaint: Location, onset, duration, radiation, frequency, intensity, character, aggravating/relieving factors, associated symptoms.

  • Body systems: Neurologic, cardiovascular, genitourinary, gastrointestinal, muscles and joints, eyes/ears/nose/throat, respiratory, skin, mental health, reproductive.

  • 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.

  • Social determinants of health: Employment, childcare, education, nutrition, housing, domestic violence, child maltreatment, discrimination, isolation.

  • Previous treatments and responses: Effectiveness and any adverse events.

  • Beliefs and expectations: Understanding of their condition, treatment expectations.

  • Red, yellow, and orange flags (sections 4 – 6).

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Meaningful Outcomes:

4. Differential Diagnosis Requiring Medical Attention

 

ACTION: Refer to emergency care immediately for red flags:

  • Shoulder Infection: Immunosuppression, recent infection or surgery, TB (tuberculosis) history, unexplained fever/chills, IV drug use, poor living conditions.

  • Traumatic Shoulder Fracture: Severe trauma.

  • 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:

  • Shoulder Malignancy: Progressive pain, history of cancer, constitutional symptoms (fatigue, weight loss, night pain).

  • 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.

  • 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).

5. Psychiatric Disorders (Orange Flags)

  • Symptoms of major depression, personality disorders, PTSD, substance addiction and abuse.

  • Screening tools: PHQ-9, GAD-7.

  • Action: Refer to appropriate provider/psychiatric specialist.

6. Psychosocial Factors (Yellow Flags)

  • 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.

  • Screening tools: PHQ-9,  GAD-7, FABQ, ORT, PCS.

  • Action: Address these as part of conservative care, co-manage, or refer to an appropriate provider.

7. Physical Examination

  • Observation: Abnormalities, asymmetries, posture, gait, movements, facial expression.

  • Range of Motion: Active, passive, resisted (flexion, extension, abduction, adduction, internal and external rotation).

  • Palpation: Bone, joint, and muscle for tenderness, swelling, muscle tightness, or temperature changes.

  • Neurological Examination: Motor strength, reflex, sensory testing (C4, C5, T1, T2); upper and lower motor neuron signs.

  • Special/Orthopedic Tests: Select as appropriate based on clinical judgment.

  • 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. Diagnostic Criteria 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.

  • Pain: Localized shoulder area with or without referred pain.

  • Signs/Symptoms: Sharp, dull, shooting, or aching pain; aggravated by specific movements; may refer into the arm.

  • 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.

  • Core Interventions:

    • Education and reassurance: Provide clear information that most soft-tissue shoulder disorders are self-limiting and do not require invasive treatments.

    • 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.

    • Maintain activities of daily living: Encourage continued movement and activity to prevent deconditioning, avoiding prolonged rest or immobilization, which can lead to stiffness.

    • Self-care: Promote home-based exercise, balanced nutrition, good sleep hygiene, stress management, maintaining a healthy body weight, and avoiding smoking/substance abuse.

    • Engage in social and work activities: Encourage social and work activities as part of the rehabilitation process.

 

  • Interventions for Shoulder Pain (Any Duration):

    • Exercise therapy:

      • Acute/subacute (≤ 3 months): Gentle range of motion (ROM) and mobility exercises, alongside light strengthening (e.g., isometric exercises).

      • Chronic (> 3 months): Progress to stretching, strengthening, and scapular stabilization exercises.

    • Cervicothoracic/thoracic spine manipulation: For shoulder pain associated with restricted movement or pain in the cervicothoracic spine.

    • Low-level laser therapy

    • Multimodal care: Heat/cold therapy, joint mobilization, and ROM exercises.

    • 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.

    • 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):

    • Laser acupuncture: If conventional treatments have not provided adequate relief.

    • Shockwave therapy: For calcific tendinitis based on imaging findings.

    • Therapeutic ultrasound: Consider for calcific tendinitis.

    • General physician care: Provide information, advice, and pharmacological pain management when necessary.

10. Prognosis

  • Recovery: Soft tissue shoulder disorders are most commonly benign and self-limited, but can recur or persist.

  • 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

  • Continuously realign treatment plan with patient’s evolving goals, feedback, outcomes, and clinical judgment.

  • Consider referral or co-management if no improvement within established timeline for treatment (e.g., 6-8 weeks).

12. Criteria for Discharge

  • Establish clear criteria for discharge (e.g., achieving initial goals, reaching a plateau, progressing signs and symptoms).

  • ​Discuss post-discharge plans, including self-management strategies and potential follow-ups.

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