This is an HTML version of an attachment to the Freedom of Information request 'Atos doctors directives'.

 
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SHOULDER PAIN 
 
                                      Version 2 Final 
 
 
 
 
 

EBM Shoulder Pain 
Version: 2 Final 
MED S2 CMEP~0049(c) 
 
 
 
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Document control 
 
Version history 
Version Date 
Comments 
2 Final 
28 March 2007 
Signed off by MSCMT 
2e (draft) 
2 March 2007 
Comments from customer incorporated 
2d (draft) 
18 December 2006 
Formatting 
2c (draft) 
04 December 2006 
External review by Dr Simon Thomas 
2b (draft) 
13 September 2006 
Internal QA by Dr G Buchanan 
2a (draft) 
 
Initial Draft 
 
 
 
Changes since last version 
EBM Shoulder Pain 
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MED S2 CMEP~0049(c) 
 
 
 
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General Information 
(painful arc, frozen shoulder, rotator cuff syndrome, glenohumeral instability or 
bursitis)  
Description 
The function of the shoulder joint is to act as an attachment for the upper limb to 
the trunk and to act as a fulcrum for its movement and thereby accurately 
positioning the hand in space.. This is achieved with a combination of 5 
articulations- the glenohumeral joint, acromioclavicular (AC) joint, subacromial 
joint (not a true synovial joint), sternoclavicular joint and the scapulothoracic joint.  
In the shoulder joint the large range of mobility is achieved at the expense of 
stability. The glenohumeral joint is held in place by a combination of bony 
contours (minimal contribution), rotator cuff tone, glenoid labrum, the tendon to 
the long head of biceps, and glenohumeral ligaments. The rotator cuff consists of 
the supraspinatus, infraspinatus, teres minor and subscapularis muscles and is 
intimately associated with the biceps tendon. 
As well as stability, movement of the shoulder 
joint depends on free movement of the rotator 
cuff, subacromial bursa and the biceps 
muscle.  
“Shoulder pain” may originate from the 
glenohumeral joint, subacromial joint, 
acromioclavicular joint, subacromial bursa, 
biceps tendon, rotator cuff, or any other surrounding structure. 
Regardless of the disorder, pain is the most common reason for consulting a 
practitioner.  There may also be significant restriction of movement. For most 
shoulder disorders, diagnosis is based on clinical features, with imaging studies 
playing a role in some people. [1] 
Aetiology  
1. Sports requiring the arm to be moved repeatedly over the head e.g. swimming, 
weightlifting and serving in tennis can lead to tearing and inflammation of the 
tendons. Reaching forward causes the humeral head to abut the acromium and 
coracoacromial ligament with rubbing and friction on the supraspinatus tendon. 
Chronic irritation leads to subacromial bursitis, tendon inflammation and tearing 
of the rotator cuff. 
2. Gleno humeral instability with laxity of the shoulder capsule and rotator cuff 
weakness. The rotator cuff functions to prevent upward displacement of the 
humeral head on the glenoid.  
 
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Weakness allows the humeral head to move upwards resulting in impingement of 
the cuff under the coracoacromial arch. 
3. Rotator cuff tendons are composed of collagen, proteoglycans and cells. The 
collagen which comprises 85% is primarily responsible for resistance of tensile 
forces. However rotator cuff tendons appear to contain increased amounts of 
glycosaminoglycans and proteoglycans compared with flexor tendons which are 
subjected to purely tensile loads. The biochemical profile of rotator cuff tendons is 
similar to that demonstrated by tendons subject to compressive as well as tensile 
loads, however microscopically they do not demonstrate the fibrocartilagenous 
appearance seen in other tendons subject to the two forms of loading. The 
relationship of this to impingement is still unclear.   
Rotator cuff injury normally follows excessive use or trauma resulting in 
inflammation of the tendons or tears of the muscles of the rotator cuff. These 
result in painful movements, often with a defined arc of pain in abduction 
between 60° to 120° and possible weakness of  one or more movements of the 
shoulder. 
4. Shoulder pain and disability are associated with several aspects of 
employment in working conditions and activities. These were primarily confined to 
men. Working with hands above shoulder level, using wrists in a repetitive way, 
stretching down below knee level and working with a bent posture all resulted in a 
risk factor of twice that of those who did not carry out such activities. Working in 
damp or cold conditions or carrying weights on one shoulder increased the risk 
fivefold [3]. 
5. Direct injury to the shoulder, often by a heavy fall, can result in contusion to the 
cuff with acute swelling and inflammation. This limits the amount of space below 
the coracoacromial arch for the rotator cuff resulting in acute impingement. 
Similarly, if enough force is transmitted to the cuff tendons, acute full thickness 
ruptures may be seen. Dislocation of the glenohumeral joint may result in rotator 
cuff tears, especially in individuals over the age of 40 years. This mechanism is 
likely to involve acute tensile overloading of the cuff as the humeral head 
dislocates out of the glenoid. 
Injury to the acromioclavicular joint in the form of subluxation or dislocation may 
occur. Degenerative arthritis may follow and if a bony spur forms this can impinge 
on the rotator cuff tendons. 
6. Calcium deposits may form around the site of injury or inflammation giving rise 
to calcific tendonitis. Although these deposits may remain asymptomatic, only 
being visible on x-ray, they can produce symptoms of discomfort or may be 
extravasated into the subacromial bursa giving rise to intense pain, loss of 
movement, severe tenderness, swelling and muscle spasm. 
 
 
 
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7.  Risk factors for frozen shoulder include female sex, older age, shoulder 
trauma, surgery, diabetes, cardiorespiratory disorders, cerebrovascular events, 
thyroid disease, and hemiplegia.  Arthritis of the glenohumeral joint can occur in 
numerous forms, including primary and secondary osteoarthritis, rheumatoid 
arthritis, and crystal arthritides.  
Shoulder pain can also be referred from other sites, in particular the cervical 
spine. 
 
 
 
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Diagnosis 
History 
As with most conditions, diagnosis is most commonly made on the basis of a 
good history, with confirmatory imaging. Details of the pain should be gained, 
including the exact site. A finger pointing to the AC joint locates the pain to that 
joint, whereas a hand covering the deltoid area suggests subacromial pathology. 
Any previous trauma should be noted, which may indicate a traumatic rotator cuff 
tear, and an interest in sports involving the upper limb can lead to muscle 
imbalance and shoulder instability.  
Examination 
Muscle wasting may be seen, especially of the deltoid. Supraspinatus, and 
infraspinatus wasting can also be seen if examined carefully. An overly prominent 
AC joint may be clearly visible. Active and passive range of movement should be 
documented, including flexion (forward elevation), abduction, external and 
internal rotation. A “painful arc”, classically seen from 60-120º abduction, with 
diminution of symptoms at >120º, is described for impingement syndrome. Pure 
glenohumeral movement is only seen with internal and external rotation, as 
flexion and abduction involve a substantial amount of scapulothoracic movement 
as well, and it can be difficult to differentiate between the two. Weakness in a 
specific movement plane compared to the contralateral arm may be a sign of 
rotator cuff tear. 
Painful arcs. 
60° to 120°     Supraspinatus tendinitis, bursitis, impingement syndrome or partial                        
tear.                                                              
100° to 140°   Osteoarthritis of the acromioclavicular joint 
Confirming diagnosis 
To date there have been no internationally agreed criteria or classification for 
signs, symptoms or severity.  
However there are a number of internationally recognised disability index 
questionnaires which have proved successful in assessing treatment outcomes 
and in longitudinal studies of natural disease progression and resolution.  The 
two most favoured are currently SPADI (Shoulder Pain and Disability Index) and 
SDQ-UK (Shoulder Disability Questionnaire). 
See appendices 1 and 2.  
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Imaging 
An AP (anterior – posterior) radiograph is a minimum necessity to confirm any 
diagnosis. Views from other angles may be helpful depending on the likely 
specific condition. MRI scanning, including MR arthrogram, or ultrasound are 
commonly used to assess the rotator cuff and biceps tendon. 
Differential diagnosis 
The most common conditions leading to pain felt around the shoulder include: 
Impingement syndrome 
Acromioclavicular degeneration/instability 
Glenohumeral instability 
Calcific tendonitis 
Adhesive capsulitis (frozen shoulder) 
Glenohumeral arthritis 
Rheumatoid arthritis 
Primary osteoarthritis 
Cuff tear arthropathy 
Post-traumatic arthritis 
Non-shoulder pathology 
Pain referred from the cervical spine/surrounding musculature  
       Diaphragmatic irritation referred to shoulder tip e.g. subphrenic abscess 
       Pain from apical lung tumour 
Axillary vein thrombosis 
Relative Prevalence 
One survey of 134 people with shoulder pain in a community based 
rheumatology clinic found that 65% of cases were due to rotator cuff lesions; 11% 
were caused by localised tenderness in the pericapsular musculature; 10% 
acromioclavicular joint pain; 3% glenohumeral joint arthritis; and 5% were 
referred pain from the neck [2]. Another survey found that, in adults, the annual 
incidence of frozen shoulder was about 2%, with those aged 40–70 years most 
commonly affected [3]. 
Apart from association with work activities of carrying over 12 kg. on one 
shoulder the  
male : female incidence was equal. Much more variability is seen with age. 
Patients under 40 years usually have instability or sports related damage with 
secondary rotator cuff impingement. Calcific tendonitis is rare under 35 years. 
Frozen shoulder and rotator cuff problems are seen in the age group 40 to 60 
years and here have to be distinguished from osteoarthritis, while shoulder pain 
in the over 60 years old group is almost certainly due to rotator cuff tear.  
 
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Impingement syndrome 
The humeral head moves below an arch made up of the acromion, 
acromioclavicular ligament, and AC joint, with the subacromial bursa and rotator 
cuff tendons (supraspinatus and infraspinatus) interposed. One of the prime 
functions of the rotator cuff is to offset the superior force generated by the deltoid 
and thereby prevent impingement of itself and the bursa between the humeral 
head and acromion. Failure of this mechanism leads to such impingement and 
further weakens the rotator cuff, worsening the condition. Over a longer period, 
attrition can result in partial or full thickness rotator cuff tears. The cause of failure 
of the rotator cuff is the subject of much controversy [4]. Primary vascular 
degeneration is thought to be the originating factor, and age is the most reliable 
associated risk. Repetitive overhead activity is also implicated, presumably from 
its attritional effect. 
Symptoms typically consist of pain in the deltoid area, felt on abduction, 
especially in the 60-120º painful arc. Weakness may ensue if the rotator cuff 
develops a rent or proceeds to full thickness tear. In a small number of people, 
advanced disease can result in “cuff tear arthropathy”, in which the biomechanics 
of the glenohumeral joint are so disordered that degenerative change becomes 
the overriding pathology, including direct bony articulation between the humeral 
head and acromial arch. Diagnosis is usually based on clinical symptoms and 
tests. A subacromial injection of local anaesthetic may be helpful in localising the 
site of pain. 
Initial treatment consists of oral anti-inflammatory drugs, with physiotherapy 
designed to strengthen the rotator cuff and thereby depress the humeral head 
away from the acromial arch [5]. Subacromial steroid injection can alleviate 
symptoms temporarily to allow successful physiotherapy [6], but may worsen 
tendon degeneration if overused [7]. If conservative management has failed, 
acromioplasty, either as an open procedure  or arthroscopically, may be 
performed with over 80% success [8]. This can be done in conjunction with 
rotator cuff repair in instances of tear. 
 
Acromioclavicular pain 
The AC joint, at the lateral end of the clavicle, is a fibrocartilagenous joint. The 
disc, interposed within the joint, begins to degenerate during the second decade 
of life. Degeneration may be accompanied by osteophyte formation, which can 
contribute in turn to rotator cuff pathology e.g. tear or impingement syndrome. 
The pain is well-localised, and exacerbated by overhead activity, as well as 
crossing the arm across the chest. Diagnosis is aided by radiography of the joint, 
which may show joint space narrowing, sclerosis and osteophyte formation. Local 
anaesthetic injection into the joint may also be helpful in confirming the site of 
pain. 
Conservative treatment consists of steroid injection into the joint, which may 
alleviate symptoms, and NSAIDs. If this fails, excision of the lateral 1cm of the 
clavicle may succeed with minimal adverse effects. 
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Glenohumeral instability 
As mentioned above, the glenohumeral joint is inherently unstable. If the soft 
tissue stabilising mechanisms fail the joint may sublux, or dislocate recurrently. 
Reasons for failure of the stabilising mechanisms may be acute or chronic and 
include: generalised soft tissue laxity, initial traumatic dislocation resulting in 
capsular/ligamentous failure, muscular imbalance through intense training (e.g. 
swimmers, throwing athletes), and developmental or traumatic bony abnormality 
[9]. 
Instability may be unidirectional (usually through a traumatic event) or 
multidirectional. Symptoms include recurrent dislocation and painful subluxation.  
Multidirectional instability is usually treated with physiotherapy, aiming to correct 
imbalance of muscular tone, especially in the rotator cuff. When this fails, 
capsular shift surgery may tighten the soft tissues and aid stability [10, 11]. 
Unidirectional instability more frequently requires surgery, as there is often an 
anatomic lesion, the Bankart lesion, which can be corrected. Anterior stabilisation 
may be performed as an open or arthroscopic procedure. There are a number of 
other procedures which have been described using different methods to provide 
stability [12]. 
There are a small number of patients who voluntarily dislocate their shoulder, 
sometimes as a “party trick”, who are known to have a reduced surgical success 
rate [13]. 
Calcific tendonitis 
Calcium deposits may form within the rotator cuff tendons, usually supraspinatus. 
The exact cause remains unclear, but degeneration and trauma are thought to be 
involved [14]. These deposits may be asymptomatic (and may be seen as an 
incidental finding on x-ray), or may become excruciatingly painful. Although the 
condition is self-limiting, subacute symptoms may last for months. Pain is felt at 
the deltoid insertion, and may mimic impingement syndrome. Diagnosis is 
confirmed on x-ray.  
In the acute stage, treatment may involve subacromial injection of local 
anaesthetic or needling of the deposit to break up the calcification and allow 
resorbtion. Despite providing transient relief, corticosteroid injection reduces 
vascular proliferation and macrophage activity, and may therefore prolong the 
underlying condition. In chronic cases, physiotherapy may be needed to retain 
range of movement, and analgesic therapies including NSAIDs, heat and 
ultrasound may be of benefit. If pain continues, surgery may be used to remove 
the calcification with good results [15].  
 
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Adhesive capsulitis (frozen shoulder) 
Frozen shoulder is frequently over-diagnosed. In true cases, for reasons that are 
unclear, the glenohumeral capsule becomes inflamed and fibrotic. The 
glenohumeral range of movement is severely restricted with associated pain [16]. 
The incidence is much higher in diabetics, and the clinical course is longer and 
less responsive to therapy, either conservative or surgical.  
The pain is of gradual onset, and will frequently interrupt sleep. The initial phase, 
from 2-9 months, is the most painful. During the next stage, the pain may subside 
but range of movement is lost. Usually, there is then a thawing phase, with 
resolution of symptoms (which may only be partial). In most cases, a course of 1-
3 years can be expected. Diagnosis requires restriction of external rotation to 
<50% that of the uninvolved arm with associated pain and an absence of other 
pathology.  
Conservative options include physiotherapy, and intra-articular steroid injection. 
Failure of conservative therapy after 6 months is an indication for operative 
intervention, which may include gentle manipulation under anaesthetic, 
arthroscopy with capsular distension by saline infusion, or capsular release [17, 
18]. Diabetic patients are known to be more refractory to surgical treatment. 
Evidence is lacking to definitively recommend one treatment over another. 
Glenohumeral arthritis 
Arthritis of the glenohumeral joint can of a number of different aetiologies, but the 
final common pathway is of degeneration of the articular surface with pain and 
reduced range of movement [19]. Unlike the larger lower limb joints, primary 
osteoarthritis is one of the is 
least common causes. 50-90% of cases of arthritis of the shoulder are due to 
rheumatoid disease. Many cases of osteoarthritis are due to altered 
biomechanics after rotator cuff tears, which allow the humeral head to sit in an 
elevated position [20]. Post-traumatic arthritis following fracture may be the cause 
in younger patients, and avascular necrosis of the humeral head may occur, 
especially in patients taking systemic steroids. 
Conservative management involves physiotherapy, NSAIDs, and intra-articular 
steroid injections. Prosthetic arthroplasty, in the form of hemi- or total shoulder 
replacement or resurfacing may be required if symptoms progress. 
Rheumatoid arthritis 
Rheumatoid arthritis can quite commonly involve the glenohumeral joint, the 
subacromial space and the rotator cuff itself can become damaged. 
 
 
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Cervical spondylosis 
This may present with shoulder pain but there is usually pain in areas outwith 
those of a C4 and C5 dermatomal distribution. There is usually a painless arc of 
shoulder movement while neck rotation or compression may trigger the pain. 
 Systemic lupus erythematosus 
S.L.E. can involve the shoulder. Anti-nuclear antibodies will be found in 96% to 
99% of cases. There may also be the appearance of the malar flush (butterfly 
rash) though this is only present in 30% of cases. 
Gout 
Gout is not uncommon in the shoulder joint, although pseudo-gout (with calcium 
pyrophosphate crystals is rarer. 
Synovial osteochondromatosis 
This condition can generate multiple loose bodies which may be seen in the joint 
and give rise to impingement syndrome. 
Haemarthrosis 
Patients on anti-coagulant therapy can present with tense shoulder joint swellings 
and global restriction of movement. They require drainage and review of 
anticoagulant medication. Shoulder effusions are rare and require further 
investigation. 
 
 
 
 
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Treatment Summary 
Rest and ice packs 
Rest of the injured tendon is the initial treatment of choice, especially with acute 
injuries or those related to repetitive movements in sports. 
Non-steroidal anti-inflammatory analgesics 
These are of particular use in the 2 - 3 weeks following onset of rotator cuff 
tendinitis to reduce both pain and inflammation. They are also useful in frozen 
shoulder, subacromial bursitis and impingement. Particularly in frozen shoulder or 
other lesions which are slow to resolve providing adequate analgesia allows 
maximum benefit to be obtained from physiotherapy and rehabilitation. 
Physiotherapy  
Uses mainly mobilisation and strengthening techniques along with massage and 
friction. 
Steroid injections 
The main rational for the use of steroid injections is to control pain. There is no 
clear evidence that they affect duration or outcome. They can be of use in painful 
frozen shoulder, resistant tendinitis or subacromial bursitis. They should be 
avoided where there is a high suspicion or a rotator cuff tear. 
Surgery 
Manipulation under anaesthetic can be required for frozen shoulder. Rotator cuff 
tendinitis due to primary subacromial impingement which has failed to resolve 
with six months of conservative treatment benfits from subacromial 
decompression. Osteophytes if present can be removed from beneath the 
acromio-clavicular joint. Full thickness tears of the rotator cuff may be surgically 
repaired. Where rotator cuff tendinitis is the result of instability in the gleno-
humeral joint with upward or forward translation of the humeral head surgical 
reduction of joint laxity is of value. 
 
 

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Prognosis 
Although there has been an assumption that shoulder problems are short lived, 
research has shown that 25% of patients presenting with an acute shoulder 
problem have had a previous episode. Similarly reassessment of reported 
disability after 6 months suggests that 50% continue to have the difficulties 
previously described and after 18 months approximately 20% continue to 
experience problems.  
The classic history of frozen shoulder is described as 6 months getting worse, 
three months static and nine months getting better.   
 
 
 
 
 
 
 
 
 
 

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Main Disabling Effects 
The main disabling effects are well summarised in a study funded by the Arthritis 
and Rheumatism Council in 1996. This assessed patients presenting in general 
practice with shoulder pain [21]. The main problems reported were pain, 
particularly with disturbed sleep, and when moving the hand and arm and 
dressing. 
84% reported sleeping less well and frequently changing position in bed. This 
correlates to the deep constant pain felt at night with frozen shoulder and rotator 
cuff tear and the inability to lie on the affected side with rotator cuff tendinitis or 
acromioclavicular joint arthritis. 
74% reported being slower getting dressed with particular problems with items 
which have to be pulled over the head and fastenings which have to be reached 
behind the neck or behind the back. This again is in keeping with the reduced 
range of movements and the painful arcs of movement related to the specific 
disorders. A smaller number reported difficulty carrying shopping (34%). This 
would be expected to be the case in rotator cuff tears where weakness is often 
seen but not in tendinitis or impingement where difficulties only begin after 70° of 
abduction. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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Appendix 1 - Shoulder Pain and Disability Index 
 
Please place a mark on the line that best represents your experience during the 
last week attributable to your shoulder problem. 
 
 
Pain scale 
How severe is your pain? 
Circle the number that best describes your pain where: = no pain and 10 = the 
worst pain imaginable. 
At its worst?                                                         0 1 2 3 4 5 6 7 8 9 10 
When lying on the involved side?                        0 1 2 3 4 5 6 7 8 9 10 
Reaching for something on a high shelf?            0 1 2 3 4 5 6 7 8 9 10 
Touching the back of your neck?                         0 1 2 3 4 5 6 7 8 9 10 
Pushing with the involved arm?                           0 1 2 3 4 5 6 7 8 9 10 
 
 
Total pain score /50 x 100 = % 
 
(Note: If a person does not answer all questions divide by the total possible score, 
eg. if 1 question missed divide by 40) 
 
Disability scale 
 
How much difficulty do you have? 
Circle the number that best describes your experience where: = no difficulty and 
10 = so difficult it requires help 
Washing your hair?                                                  0 1 2 3 4 5 6 7 8 9 10 
Washing your back?                                                0 1 2 3 4 5 6 7 8 9 10 
Putting on an undershirt or jumper?                        0 1 2 3 4 5 6 7 8 9 10 
Putting on a shirt that buttons down the front?        0 1 2 3 4 5 6 7 8 9 10 
Putting on your pants?                                             0 1 2 3 4 5 6 7 8 9 10 
Placing an object on a high shelf?                           0 1 2 3 4 5 6 7 8 9 10 
Carrying a heavy object of 10 pounds (4.5kg)         0 1 2 3 4 5 6 7 8 9 10 
Removing something from your back pocket?         0 1 2 3 4 5 6 7 8 9 10 
 
Total disability score: _____/ 80 x 100 = % 
 
(Note: If a person does not answer all questions divide by the total possible score, 
e.g. if 1 question missed divide by 70) 
 
 
Total Spadi score: _____ 130 x 100 = % 
 
(Note: If a person does not answer all questions divide by the total possible score, 
eg if 1 question missed divide by 120) 
Minimum Detectable Change (90% confidence) = 13 points 
(Change less than this may be attributable to measurement error) 
 
Source: Roach et al. (1991). Development of a shoulder pain and disability index. 
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Appendix 2 - SDQ items 
 
 
1 I wake up at night because of shoulder pain. 
 
2 My shoulder hurts when I lie on it. 
 
3 Because of pain in my shoulder it is difficult to put on a coat or a sweater. 
 
4 My shoulder hurts during my usual daily activities. 
 
5 My shoulder hurts when I lean on my elbow or hand. 
 
6 My shoulder hurts when I move my arm. 
 
7 My shoulder hurts when I write or type. 
 
8 My shoulder is painful when I hold the driving wheel of my car or handle bars of my 
bike. 
 
9 When I lift and carry something my shoulder hurts. 
 
10 During reaching and grasping above shoulder level my shoulder hurts. 
 
11 My shoulder is painful when I open or close a door 
 
12 My shoulder is painful when I bring my hand to the back of my head. 
 
13 My shoulder is painful when I bring my hand to my buttock. 
 
14 My shoulder is painful when I bring my hand to my low back. 
 
15 I rub my painful shoulder more than once during the day. 
 
16 Because of my shoulder pain I am more irritable and bad tempered with people 
than usual. 
 
 
 
 
 
Measuring shoulder disability 
87 
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REFERENCES 
 
[1]   Clinical Evidence  February 2006 
 
[2]   Pope DT. et al.  The frequency of restricted range of movement in individuals 
        with self- reported shoulder pain : results from a population based  survey. 
       Br J Rheumatol.  1996 Nov; 35(11): 1137 – 1141 
 
[3]   Lundberg B. The frozen shoulder. Acta Orthop Scand 1969:suppl 119. 
 
[4] Ozaki J et al Tears of the rotator cuff of the shoulder associated with pathological 
changes in the acromion. JBJS(Am) 1988;70(A):1224-1230 
 
[5] Wirth MA et al. Nonoperative management of full-thickness tears of the rotator cuff 
     Orthop Clin North Am 1997;28:59-67 
 
[6] Nirschl RP  Prevention and treatment of elbow and shoulder injuries in the tennis               
player. Clinical Sports medicine 1988;7:289-308 
 
[7] Ford LT, DeBender J  Tendon rupture after local steroid injection. Southern                      
Medical Journal 1979;72:827-830 
 
[8] Checroun AJ et al. Open versus arthroscopic decompression for subacromial         
impingement. A comprehensive review of the literature from the last 25 years. Bull 
Hosp Joint Dis 1998;57:145-151 
 
[9] Matsen FA et al Anterior glenohumeral instability In The Shoulder (ed CA   
Rockwood and FA Matsen) p611-754 WB Saunders Piladelphia PA  
 
[10] Pollock RG et al Operative results of the inferior capsular shiftprocedure for     
multidirectional instability of the shoulder. JBJS (Am) 2000;82(A):919-928 
 
[11] Gartsman GM et al Arthroscopic treatment of multidirectional glenohumeral 
instability Arthroscopy 2001;17:236-243 
 
[12] Nelson BJ, Arciero RA Arthroscopic management of glenohumeral instability  Am 
J Sports Med 2000;28:602-614 
 
[13] Calvert P Shoulder instability 2. Classification and clinical assessment Current 
Orthopaedics 1996;10:151-7 
 
[14] Re LP, Kerzel RP Management of rotator cuff calcifications Orthopaedic clinics of  
North America 1993;24:125-32 
 
[15] Gschwend N et al Die tendonitis calcarea des Schulterglenks 
 Orthopade 
1981;10:196-205 
 
[16] Goldberg BA et al Management of the stiff shoulder 
 
J Orthop Sci 1999;4:462-471 
EBM Shoulder Pain 
Version: 2 Final 
MED S2 CMEP~0049(c) 
 
 
 
Page  17 
 

 
Medical Services  
 
 
[17] Dodenhoff RM et al Manipulation under anaesthesia for primary frozen 
shoulde:effect on early recovery and return to activity J Shoulder Elbow Surg 
2000;9:23-26 
 
[18] Pearsall AW et al An arthroscopic technique for treating patients with frozen 
shoulder Arthroscopy 1999;15:2-11 
 
[19] Cofield RH  Degenerative and arthritic problems of the glenohumeral joint 
 In 
The Shoulder (ed CA Rockwood and FA Matsen)Vol 2 p678-749, WB 
Saunders, Philadelphia PA  
 
[20] Neer CS et al Cuff tear arthropathy JBJS(Am) 1983;65A:1232-44 
 
[21]   Croft P. et al.  The clinical course of shoulder pain: prospective cohort study in  
          primary care. Primary Care Rheumatology Soc. Shoulder Study Group 
          BMJ.  1996 Sep 7; 313(7057): 601 - 602 
 
 
EBM Shoulder Pain 
Version: 2 Final 
MED S2 CMEP~0049(c) 
 
 
 
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