An increasing number of patients are being referred from primary care for ultrasound scans of the shoulder for non-traumatic conditions related to the rotator cuff or the shoulder joint, and for ultrasound guided shoulder injections. This is against evidence-based practice and current clinical recommendations. It is delaying onward referral to the specialist services and delaying treatment, besides causing unintended health anxieties for patients.

Guidance: Imaging in primary care

Ultrasound or MRI is not indicated for initial management in primary care of patients with non-trauma shoulder pain, including:

  • Sub-acromial impingement
  • Sub acromial bursitis
  • Rotator cuff tendinopathy
  • Calcific tendinitis
  • Glenohumeral and acromioclavicular arthritis

X-rays

X-rays should be used routinely and would be the ideal imaging to be done in primary care. First line management could also include appropriate analgesia and self-managed initial rehabilitation regime.

Condition

MRI/Ultrasound

Referral pathway

Non-traumatic pathology related to the rotator cuff or the shoulder joint- not improving despite first line management

None in primary care
  • Self-referral if diagnosis clear and only physiotherapy input needed
  • Referral to IMPReS via SPOA for unclear diagnosis/further investigations.

Patients with shoulder weakness following trauma

 

 

None in primary care
  • full clinical assessment in primary care
  • Fracture clinic referral as urgent
  • Referral to UCC if trauma and weakness is significant

Any suspected fractures/dislocation, sepsis

None in primary care

Referral to UCC/A&E

Suspected serious pathology

Appropriate investigation in Primary care (Bloods, Imaging)
  • 2-week rule referral as indicated
  • Referral to A&E if sepsis suspected

 

Guidance for shoulder injections in primary care

Condition

MRI/Ultrasound

Clinical pathway

Shoulder injections for non-traumatic pathology related to the rotator cuff or the shoulder joint

None

 

 

 

 

 

 
  • Injections should be done in conjunction with a suitable rehabilitation programme for the condition.
  • Image guided shoulder injections for these conditions are not usually needed (see guidance below)
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