General practitioners are commonly presented with shoulder pain in their practice, where they are well-positioned to detect and administer first-line treatment for the underlying conditions. Read on for a review of common shoulder conditions and their management in primary care.
Shoulder pain is a common presenting complaint seen
in the primary care setting. Its causes may include:
Frozen shoulder, or adhesive capsulitis, is the most
common shoulder condition affecting middle-aged to
The upper limbs are frequently used in daily
life, and any impairment due to pain and
stiffness can limit activities of daily living,
such as dressing or self-care, and may
also result in difficulties with sleep or
lying on the affected side.
The common presenting complaints, signs and
symptoms during physical examination, and treatment
options for the various common conditions are
summarised in Table 1. Very often, a patient may have several co-existing conditions and thus present with a
mixture of complaints, signs and symptoms.
It is important to exclude a cervicogenic source of pain
by taking a history of neck pain, radiating pain down
the forearm and numbness in the upper limb. It is also
important to rule out non-orthopaedic differentials of
shoulder pain, such as cardiac or gallbladder disease.
Signs and symptoms
Limited active and
Glenohumeral joint H&L and
and manipulation under anaesthesia
Rotator cuff tendinopathy, rotator cuff tear
pain and/or weakness
Weakness, painful arc,
drop arm sign positive
Not recommended for rotator
Subacromial impingement / bursitis
pain in certain positions
positive, Neer’s test
Biceps tendinopathy, biceps tear
Bicipital groove tenderness, Speed’s test positive, Yergason’s test positive, Popeye sign if
biceps tenotomy or tenodesis
Acromioclavicular joint (ACJ) osteoarthritis
Acromioclavicular joint H&L
excision of distal clavicle
Glenohumeral joint osteoarthritis
Shoulder pain and/or stiffness
Limited active and
passive range of motion
Cuff tear arthropathy
Shoulder pain and/or weakness
Table 1 Common shoulder conditions and their presenting complaints, signs and symptoms and treatment optionsH&L: Hydrocortisone and lignocaine
X-rays, ultrasounds and magnetic resonance imaging
(MRI) scans are the commonly performed investigations
for shoulder pain work-up.
In the context of trauma, basic X-rays are required to rule out fractures and dislocations. X-rays are
recommended to rule out glenohumeral joint arthritis
when diagnosing frozen shoulder. It can also serve as
a baseline investigation and pick up acromioclavicular
joint arthritis and subacromial spurs.
An ultrasound of the shoulder is useful to look for
other concomitant conditions such as rotator cuff
tears, subacromial bursitis and biceps tendinopathy.
However, it is unable to pick up intra-articular lesions
such as labral tears.
MRI is the most advanced imaging technique and
also the most expensive. It allows for assessment of
all the above conditions, and is the preferred mode of
imaging for preoperative planning.
For patients with frozen shoulder, screening for
diabetes mellitus is recommended in view of the
high correlation between the two conditions.
Oral analgesia and lifestyle modifications
In the primary care setting, oral analgesia such as
paracetamol and non-steroidal anti-inflammatory
drugs (NSAIDs) should be prescribed for pain relief.
Topical NSAIDs may also be prescribed for more
targeted local effect.
Inflammation from bursitis and arthritis may be
improved from the use of NSAIDs. Advice for lifestyle
modification may also be beneficial.
For most shoulder conditions, a trial of physiotherapy
for at least a few months is recommended. Physiotherapy exercises can help improve shoulder
range of motion and muscle strength, to help patients
improve their abilities to perform daily activities.
If the symptoms are severe and debilitating, and
after failure of conservative management, different surgical options as detailed in Table 1 may be
considered. Surgery is usually performed arthroscopically
using a few keyhole incisions, except for
arthroplasty ( joint replacement) which requires an
The choice of procedures required will be
individualised to the patient’s signs, symptoms
and underlying condition(s), with the appropriate
procedures performed to address each individual
Surgery is also the only way to repair a torn rotator
cuff. The other treatments mentioned above will
not ‘cure’ it, but may help alleviate the patient’s
symptoms. For young patients with an acute,
traumatic rotator cuff tear, early surgery is recommended.
Otherwise, a trial of physiotherapy is
However, in certain cases of unrepaired rotator
cuff tear, there is a risk of progression of the size of
rotator cuff tear, and subsequently to end-stage cuff
In the younger population, shoulder dislocation is the
most common shoulder complaint. Traumatic shoulder
injuries may occur at any age, and are commonly
associated with labral tears in young patients and
rotator cuff tears in older patients.
Anterior dislocation is the most common direction of
shoulder dislocation. It is usually a result of trauma,
although recurrent dislocation may also be atraumatic.
Posterior dislocation may be the result of electrocution
Clinically, painful range of motion and squaring of the
shoulders is suspicious for dislocation.
X-rays, particularly axial or Velpeau views, are useful
to diagnose dislocation, and to confirm enlocation
after manipulation and reduction.
After reduction, MRI is the investigation of choice as it
can pick up labral tears, Hill-Sachs lesions, and other
intra-articular pathologies. For an elderly patient
who suffers a dislocation, a rotator cuff tear is not
uncommon and can be picked up on MRI as well.
With recurrent dislocations, there may be anterior
glenoid bone loss or a large Hill-Sachs lesion.
Occasionally, a computed tomography (CT) scan
may be required for better assessment of the bony
defect for surgical planning.
Acute management of a dislocated shoulder involves
manipulation and reduction under sedation. This is
commonly done in the emergency department. After
reduction, an arm sling may be used for support and
to immobilise temporarily until the pain resolves.
The recommended treatment for recurrent shoulder
dislocation is surgery. This may include labral repair, capsular plication, remplissage and/or bone block
procedures. At the time of surgery, other concomitant pathologies may also be addressed.
Physiotherapy for strengthening of the rotator cuff
muscles is also a crucial adjunct to prevent recurrence.
Analgesia, lifestyle modifications and physiotherapy
are the first-line treatment for most shoulder conditions.
Injections may be a useful adjunct in certain conditions.
Surgical intervention should be considered after
failure of conservative management. Surgery is the
recommended initial treatment in certain cases, such
as for young patients with an acute traumatic rotator
cuff tear and for patients with recurrent shoulder
Dr Benjamin Ang is an Orthopaedic Surgeon with the Department of Orthopaedic Surgery
in Singapore General Hospital. He is an avid sportsman and has previously represented
Singapore at international competitions in track & field and floorball. With first-hand
experience and a personal understanding of an athlete’s psyche, he sub-specialises in sports orthopaedics. His interests lie in managing shoulder, hip and knee conditions. He
was awarded the Ministry of Health HMDP (Health Manpower Development Plan) award
for further fellowship training in hip surgery in Switzerland.
GPs who would like more information about these conditions and procedures may contact
Dr Ang at firstname.lastname@example.org.
GP Appointment Hotline: 6326 6060
GPs can visit the website for more information about the department.
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