Rotator Cuff Tendinopathy (Impingement)
Referrals for USS guided steroid injections to RCHT Clinical Imaging have restarted. Please note there is limited capacity so referrals should be reserved for patients with significant disabling and persistent symptoms. Please click here for full details
Covid-19 Update: Corticosteroid Injections During The Coronavirus Pandemic
Please note that any patients considering steroid injections during the Coronavirus pandemic require a risk assessment and counselling on increased risks with Covid prior to performing. Secondary care referrals for steroid injection, including image guided injections, require the patient to be counselled and risk assessed prior to referral and this documented in the referral. Please see guidance available here for detailed information.
Consider referral for surgery for Impingement syndrome if:
Poor response to conservative measures listed below
Significant Sub-acromial spurring reported on plain film
AND
Willing to consider surgery
Significant acromial spurs or chronic impingement on X ray makes conservative management less likely to success and may put the rotator cuff at risk.
A Shoulder X Ray within 6 months is required for the referral
Primary care management / investigations
Most people respond to conservative measures within 6 months:
- Tailored Analgesia
- Advice to avoid aggravating exercise
- Physiotherapy – resolves majority of cases
- Discourage use of arm slings
- Steroid injection into sub-acromial space – trial of 2 injections
British Elbow and Shoulder Society Shoulder Pain exercise videos Exercises for Shoulder Pain – British Elbow & Shoulder Society (bess.ac.uk)
Imaging may not be able to detect / exclude impingement
Ultrasound if there are symptoms and signs suggestive of a rotator cuff tear. Follow Rotator Cuff Tear guidelines
Consider referral to the MSK Interface Service if:
- Conservative measures have failed including a course of tailored physiotherapy
- Diagnostic uncertainty (including if not sure whether surgery is indicated)
Exclusion Criteria
- Red flag pathology
- Severe symptoms with functional limitations and willingness for surgery
- Previous joint replacement or significant major surgery to the same joint
- Patients under 16 years
- Hand and foot problems
- Spinal problems (see Spinal Interface)
- Multiple/inflammatory arthropathy
- Lumps, bumps, ganglia
A Shoulder X Ray within 6 months is required for the referral
Contributors
Mr Jeremy Dainton, Consultant Orthopaedic Surgeon, Royal Cornwall Hospitals NHS Trust
Mr Sean Dixon, Consultant Orthopaedic Surgeon, Royal Cornwall Hospitals NHS Trust
Annie Rae, Specialist Extended Scope Physiotherapist, Royal Cornwall Hospitals NHS Trust
Deanne De Beer, Specialist Extended Scope Physiotherapist, Royal Cornwall Hospitals NHS Trust
Dr Katy Bray, GP with Specialist Interest Orthopaedics, Three Spires Medical Practice
Dr Rebecca Hopkins, GP and RMS Orthopaedic Guidelines Lead, Kernow Referral Management Service
Date reviewed 11/03/2022
Next review due 11/03/2023
Sifter name Dr Rebecca Hopkins
Version 2.2