Shoulder and Elbow

• The shoulder and elbow service deals with the management of all patients with musculoskeletal (MSK) conditions of the upper limb (UL), (excluding hand and wrist problems) which might benefit from surgical management, including fractures and dislocations, instability, joint disorders, tendon disorders, ligament injuries, cartilage injuries, or other specialist procedures (e.g. difficult joint injections).
• Shoulder and Elbow Surgery opinion in NHS Tayside is provided by Orthopaedic Upper Limb specialist surgeons, and Advanced Practice Physiotherapists
• Many UL conditions are self-limiting and can be managed appropriately in primary care by a GP or First Contact Physiotherapists (FCP) and the MSK Physiotherapy service. If the patient is attending NHS physiotherapy, onward referral to UL service, if appropriate, will be organised by Physiotherapy service without the need for further GP intervention.
   

• Blood tests should be performed if malignancy, polymyalgia rheumatic, inflammatory arthritis or sepsis are suspected.
• Testing for diabetes should be considered for people with frozen shoulder.
• X-rays should be considered if: there is a history of trauma; there is little improvement with conservative treatment; symptoms last more than four weeks, there is severe pain or restriction of movement, suspected arthritis or any red flags are present.

• Some acute cases e.g. fractures, dislocations, significant soft tissue injuries, bone or joint infections, possible cancer, clearly require urgent referral for specialist assessment /management and can be referred to the fracture clinic via our on-call service
• Red flags include: (Link to British Elbow and Shoulder Society poster)
  • Trauma, pain and weakness – could indicate possible fracture, acute cuff tear
  • Any unexplained mass or swelling - could indicate possible tumour
  • Red skin, fever, chills, hot, swollen joints or systemically unwell - could indicate possible infection, septic arthritis
  • Trauma / epileptic fit /electric shock leading to loss of rotation and abnormal shape - could indicate possible unreduced dislocation
  • Systemically unwell patients with signs of inflammatory disease (stiffness >30mins, fever, rash, weight loss, warm/swollen joints) - could indicate possible RA. Referral to Rheumatology may be appropriate
  • Compartment Syndrome/Acute ischaemia (not Raynaud’s).
  • Unexplained significant and worsening sensory or motor deficit.

• The UL service is happy to accept referrals where the diagnosis of an MSK problem is unclear. Such patients should have appropriate work-up and should have been seen by a Physiotherapist unless there is a suspicion of cancer or infection where referral is required.
• Where a non-acute shoulder or elbow condition which fails to respond to initial Primary Care management requires specialist referral for advice, assistance with management or possible surgical intervention, they should be referred to the Orthopaedic elbow and shoulder Service. The referral will be vetted by any member of the multidisciplinary team, and assigned to the most appropriate member of the team. Please be aware that the first point of contact may be an advanced practice Physiotherapist
• Where a referred patient may be more appropriately seen by another speciality, the referral may be redirected appropriately. The referrer will be informed as per TNHS access policy

• Rule out non MSK issues: Visceral disease: any condition that irritates the mediastinal pleura, pericardium or diaphragm can cause shoulder pain. Consider myocardial ischaemia.
• Pain referred from the cervical or thoracic spine – MSK Physiotherapy should be the first option.
• Sensory neuropathies of less than 6 weeks duration with no conservative treatment tried.
• Long head of Biceps ruptures at shoulder - not routinely repaired. Refer MSK physiotherapy if pain predominant feature. (However, generally distal biceps rupture will need surgery in young and active individuals.)
• Insufficient work-up. Appropriate clinical work-up and full treatment programme is advised prior to referral. Physiotherapy is first line management for most upper limb complaints, +/- corticosteroid injections. MSK Physiotherapy colleagues can inject, and request most imaging as necessary if onward referral is required.  Occasionally, referrals have insufficient information to vet appropriately. Where there is insufficient information to guide referral management, we may ask for further information or investigation to be requested to assess the need for appointment, while holding the referral.
• When it is clear that surgery is either not appropriate or that there is no surgical solution for a problem, referrals may be returned to the referring clinician with an explanation of the decision making and advice to the referrer where appropriate.

Emergency Referrals: For upper limb injuries or suspected infection, referral for advice or assessment should be made to the oncall orthopaedic Surgery Registrar via the Ninewells switchboard. Bleep 4561. We would recommend putting a small note, post referral, of the plan made after discussion so the patient, GP practice and referral unit is aware.

Suspected Cancer: For assessment / opinion on tumours or possible cancer, we do not have a specialist tumour clinic. Referrals should be made to the appropriate subspecialty clinic according to the location of the tumour or age of the patient (NB paediatric patients). Where there is a possibility or suspicion of malignancy, the 'urgent – suspected cancer' priority option should be selected on SCI Gateway or the written referral marked appropriately (see referral guidance on Referrals of Musculoskeletal Tumours).

Urgent, routine or request for advice Outpatient referrals through SCI Gateway Orthopaedic/Elbow and shoulder surgery service.

Named Referrals to specific consultant or other clinician may be appropriate if the patient has previously been seen by that clinician for the same problem, however an appointment with that consultant cannot be guaranteed. For referrals regarding a new problem, a named referral request cannot be guaranteed. Please advise the patient that they may be seen by any member of the multidisciplinary team.

Exercises for Shoulder Problems (includes videos) NHS Inform 
British Elbow and Shoulder Society national guidelines
British Elbow and Shoulder Society Patient care Pathways
British Elbow and Shoulder Society Patient information
ShoulderDoc website
ShoulderDoc patient info