Scans for shoulder pain and guided injections for shoulder pain
Best Practice Guidance
How up to date is this information?
Published January 2020 | Last reviewed September 2024
Using this guidance
The guidance set out here was reviewed extensively in the Autumn of 2024. There are no plans for any further reviews.
Medicine is constantly evolving and over time it is inevitable that the evidence base will change. Please use your own judgement and/or other sources of clinical guidance alongside the information set out here.
Please note this guidance is a recommendation and it should be used in the context of the overall care pathway and when all alternative interventions that may be available locally have been undertaken.
Summary
W(i) Scans for shoulder pain
X-rays should be used routinely as the first line of radiological investigation for the diagnosis of most routine shoulder pathology. This practice should be followed in primary, intermediate and secondary care.
The use of Ultrasound, MRI and CT scanning should be restricted to those secondary care services that are responsible for the definitive treatment of such patients. The use of these investigations outside secondary care should only be allowed if referral pathways have been developed with the local secondary care specialist shoulder service.
Primary care patients that are deemed urgent or have red flags should be referred urgently to the appropriate secondary care team.
W(ii) Image guided injections for shoulder pain
Image guided subacromial injections are not recommended in primary, intermediate or secondary care. Evidence does not support the use of guided subacromial injections over unguided subacromial injections in the treatment of subacromial shoulder pain.
Other image guided shoulder injections should only be offered under the guidance of a secondary care shoulder service.
This guidance applies to adults aged 19 years and over.
Recommendation
For patients who initially present with shoulder pain in primary or intermediate care, the first line of radiological investigation should be a plain x-ray. X-rays diagnose most routine shoulder problems such as osteoarthritis, calcium deposits, rotator cuff arthropathy, impingement, fractures and primary and secondary tumours.
If following an x-ray and clinical assessment, the diagnosis is still in doubt then a referral to the secondary care shoulder service is indicated where further specialist assessment and appropriate investigations including USS, CT scans and MRI scans can be arranged. The British Elbow and Shoulder Society (BESS) have produced treatment and referral guidelines for routine shoulder conditions.
If shoulder RED FLAGS are present, an urgent referral to secondary care should be arranged for further investigation and management:
- Any history or suspicion of malignancy
- Any mass or swelling
- Suggestions of infection, e.g. red skin, fever or systemically unwell
- Trauma, pain and weakness
- Trauma, epileptic fit or electric shock leading to loss of rotation and abnormal shape.
Injections for shoulder pain are often indicated as a first line of treatment. The common areas injected are the subacromial space, the glenohumeral joint and the acromioclavicular joint. The most common injection is a subacromial injection. Guided injections (usually utilising ultrasound) are more expensive than unguided injections.
Evidence now indicates there is no additional benefit from a guided subacromial injection over an unguided landmark injection and so these are no longer recommended in primary, intermediate and Secondary care during routine management of patients with subacromial shoulder pain.
The use of other guided injections for glenohumeral joint and acromioclavicular joint problems should only be offered under the guidance of a secondary care shoulder service responsible for definitive treatment of these patients.
Rationale for recommendation
There is now a very significant burden on radiology departments from an expanding list of investigations and interventional treatments being offered to a variety of services in primary, intermediate and secondary care. While there is no obvious harm directly caused by these investigations, the waiting times are becoming excessive and such delays may cause harm. It appears that a large number of these investigations may add little clinical value to the treatment pathway but cause unnecessary delay to those patients in need and so adversely affecting their outcome. Practices vary but overall there are large volumes of referrals for X-rays, MRIs, CTs and ultrasounds.
With little evidence to support the escalating use of shoulder scans by all, a restriction of these investigations to the secondary care services directly responsible for the definitive treatment of such patients is recommended. Any primary or intermediate care services requesting such scans should be under local referral guidelines developed with the local specialist shoulder service. This will likely decrease unnecessary referrals and improve patient experience and waiting times.
The burden of referrals for guided shoulder injections, particularly subacromial injections in secondary care has also expanded significantly in recent years and is compounded further by the need for a radiologist to perform or supervise the scan/injection. While the offer and provision of such injections by intermediate care providers may seem attractive, evidence now suggests no additional benefit to be had from more expensive guided subacromial injections over standard unguided ones.
The restriction of guided subacromial injections will lead to more immediate unguided injection treatments for patients by their consulting clinician and will improve radiology waiting times for other patients in need of other interventional radiology treatments further improving patient experience and waiting times.
Patient information
There is no specific EBI patient guidance for this intervention.
However, we recommend using the BRAN principles (Benfits, Risks, Alternatives and do Nothing) when speaking with patients about this.
Further information on patient involvement in EBI can be found on the EBI for patients section.
Coding
Shoulder Pain Scans WHEN (( Any_Appointment_Procedure LIKE '%U13[23456]%' OR Any_Appointment_Procedure LIKE '%U21[1267]%' OR Any_Appointment_Procedure LIKE '%U365%') AND ( Any_Appointment_Procedure LIKE '%Z54[289]%' OR Any_Appointment_Procedure LIKE '%Z68[89]%' OR Any_Appointment_Procedure LIKE '%Z81[123489]%') ) -- Age Between 19 and 120 AND ISNULL(OPA.Age_at_Start_of_Episode_SUS,OPA.Der_Age_at_CDS_Activity_Date) between 19 AND 120 THEN '2W_I_shoulder_imaging_I' Guided Shoulder Injections WHEN ( Any_Appointment_Procedure like '%U13[23456]%' OR Any_Appointment_Procedure like '%U21[1267]%') AND ( Any_Appointment_Procedure like '%Z81[23489]%' OR Any_Appointment_Procedure like '%Z891%' OR Any_Appointment_Procedure like '%Z54[289]%' OR Any_Appointment_Procedure like '%Z68[89]%') AND Any_Appointment_Procedure LIKE '%W90[34]%' -- Age Between 19 and 120 AND ISNULL(OPA.Age_at_Start_of_Episode_SUS,OPA.Der_Age_at_CDS_Activity_Date) between 19 AND 120 THEN '2W_II_shoulder_guided_injections'
Exclusions
WHERE 1=1 -- Patient Has Attended Appointment AND Attendance_Status IN (5,6) -- Cancer Diagnosis Exclusion Codes AND (( Any_Appointment_Diagnosis not like '%C[0-9][0-9]%' AND Any_Appointment_Diagnosis not like '%D0%' AND Any_Appointment_Diagnosis not like '%D3[789]%' AND Any_Appointment_Diagnosis not like '%D4[012345678]%') OR Any_Appointment_Diagnosis IS NULL) -- Private Appointment Exclusion AND opa.Administrative_Category<>'02'
References
- NICE Clinical Knowledge (2017) Summary on Shoulder Pain Management.
- BESS/BOA Patient Care Pathways Subacromial shoulder pain R Kulkarni, J Gibson, P Brownson, M Thomas, A Rangan, A Carr and J Rees. Shoulder & Elbow 2015, Vol. 7(2) 135–143.
- The Oxford Shoulder Clinic at the Nuffield Orthopaedic Centre. Diagnosis of Shoulder problems in Primary Care poster.
- The British Shoulder and Elbow Society (BESS) and the British Orthopaedic Association (BOA) have produced updated Shoulder Diagnosis, Treatment and Referral Guidelines for Primary, Community and Intermediate Care. These can be found in Appendix 3 of the List 2 Guidance and have been produced in response to comments from clinicians and patients during the EBI consultations, to assist with education and safe implementation of the EBI W1 and W2 shoulder radiology recommendations.
- Optimising outcomes of exercise and corticosteroid injection in patients with subacromial pain (impingement) syndrome: a factorial randomised trial. Roddy E, Ogollah RO, Oppong R, Zwierska I, Datta P, Hall A, Hay E, Jackson S, Jowett S, Lewis M Shufflebotham J, Stevenson K, van der Windt DA, Young J, Foster NE. Br Journal of Sports Medicine.
