Definitions for the Levels of Evidence (1++, 1+, 1-, 2++, 2+, 2-, 3, 4) and Grades of Recommendation (A-C, I, and Good Practice Points) are given at the end of the "Major Recommendations" field.
Initial Diagnosis and Management
Recommendation*
A If a significant rotator cuff tear is suspected, refer for diagnostic ultrasound.
Good Practice Points**
Diagnostic ultrasound should be undertaken by a radiologist with appropriate expertise.
Indications for radiography
- Strong suspicion of fracture
- Dislocation if aged >40 years or if clinically indicated
- Where surgery is being considered as a management option
Recommended views
- Anteroposterior (AP) glenoid fossa (Grashey) view
- Outlet or lateral scapular view
- Axial view
Plain films are best requested by a specialist, for people referred with shoulder problems that have not responded to nonoperative management or where surgery is being considered as a management option.
Refer people with red flags immediately for specialist evaluation.
Refer people with displaced and/or unstable fractures, massive tears of the rotator cuff, severe dislocations, and failed attempts at reduction urgently for specialist evaluation.
Rotator Cuff Disorders
Recommendations*
B Prescribe nonsteroidal anti-inflammatory drugs (NSAIDs) with caution. They provide short-term symptomatic pain relief, but can have serious consequences.
B Use subacromial corticosteroid injection with caution. It provides short-term symptomatic relief for people with tendinosis and partial thickness tears.
B Provide a trial of supervised exercise by a recognised treatment provider for people with rotator cuff disorders.
B Avoid use of therapeutic ultrasound (no additional benefit over and above exercise alone).
Good Practice Points**
Simple analgesics provide pain relief with less potential for serious side effects.
Informed consent for subacromial steroid injection should include the risk of infection (very rare), transient red face particularly in women, and sometimes "post-injection flare of pain."
Subacromial corticosteroid may be appropriate for full thickness tears as part of long-term management where surgery is not being considered as a treatment option.
If there is no significant improvement in those with a full thickness tear of the rotator cuff after 4 to 6 weeks of nonoperative management, refer to an orthopaedic specialist.
Early surgical management for a rotator cuff tear has the most to offer people with otherwise healthy tissue and who are physiologically young and active.
Frozen Shoulder
Recommendations*
B Actively consider intra-articular corticosteroid injection performed by an experienced clinician in the painful phase of a frozen shoulder.
B If required, offer supervised exercise by a recognised treatment provider to improve range of movement after the acute pain has settled.
Good Practice Points**
Informed consent for an intra-articular steroid injection should include likelihood of pain, the risk of infection (very rare), transient red face particularly in women, and sometimes "post-injection flare of pain."
People with diabetes should have their blood sugar levels monitored following corticosteroid injection and there should be appropriate contingency plans in place if hyperglycaemia occurs.
Avoid vigorous stretching in the early painful phase of a frozen shoulder as it will exacerbate pain.
It is most important that people with a frozen shoulder understand the time it takes for this condition to resolve.
Glenohumeral Instabilities
Recommendation*
A Young adults engaged in demanding physical activities with a first traumatic shoulder dislocation should be referred for orthopaedic evaluation.
Good Practice Points**
Investigations
- Prereduction x-ray is recommended in people aged >40 years.
- Post-reduction x-ray is recommended for all people with an acute first time dislocation to confirm the reduction and assess for bony injury.
- X-ray is required for all people with a failed attempt at reduction.
- X-ray is recommended for those with recurrent dislocation where surgical stabilisation may be a management option.
Acute Management
- Only clinicians with appropriate expertise should reduce anterior or posterior dislocations.
- Relaxation is critical for successful reduction. Ensure adequate analgesia is given, if required, before attempting reduction.
- Attempt slow steady traction for at least 30 seconds.
- Avoid excessive force while attempting to reduce a dislocated shoulder.
- Urgent referral to an orthopaedic specialist is required when reduction is unsuccessful after two attempts.
Post-Reduction Management: Nonoperative
- In people with a primary dislocation for whom nonoperative management is appropriate, apply a sling, provide analgesia, and refer for a supervised exercise programme.
- Following dislocation, people should not return to sport for at least 6 weeks, or when they have achieved near normal muscle strength.
Recurrent Dislocation
People with recurrent dislocation (>2) should be referred to an orthopaedic specialist to evaluate the need for surgical stabilisation.
Acromioclavicular (AC) Joint Disorder
Good Practice Points**
Imaging
- If surgery is an option for an AC joint dislocation, perform x-rays to stage the degree of dislocation.
Management
- People with Grade I and II sprains can be provided with a sling and analgesics for 5 to 7 days until comfortable.
- Advise gradual return to activity as symptoms settle, and avoidance of heavy lifting and contact sports for 8 to 12 weeks.
- People with Grade III AC joint sprains can also be managed nonoperatively but if this is not successful after 3 months, consider referral to a specialist for further evaluation.
- More serious AC joint dislocations require referral for orthopaedic evaluation.
Sternoclavicular (SC) Joints Disorder
Good practice Points**
Although rare, clinicians should watch for pulmonary or vascular compromise due to a posterior dislocation of the SC joint usually resulting from severe compression trauma. Immediate referral to an appropriate specialist is indicated.
Most injuries of the SC joint are mild sprains and can be managed with a sling, analgesics, and return to activity as tolerated.
Cultural Considerations
Recommendation*
C Health care practitioners providing care for Maori and Pacific peoples should be sensitive to their particular needs.
*Grades indicate the strength of supporting evidence, rather than the importance of the recommendations.
**Recommended practice based on the professional experience of the Guideline Development Team where there is no evidence available.
Definitions:
Levels of Evidence
1++
High quality meta-analyses, systematic reviews of radomised controlled trials (RCTs), or RCTs with a very low risk of bias
1+
Well conducted meta-analysis, systematic reviews of RCTs, or RCTs with a low risk of bias
1-
Well conducted meta-analysis, systematic reviews of RCTs, or RCTs with a high risk of bias
2++
High quality systematic review or case-control or cohort studies; high quality case-control or cohort studies with a very low risk of confounding, bias, or chance and a high probability that the relationship is causal
2+
Well conducted case-control of cohort studies with a low risk of confounding, bias, or chance and a moderate probability that the relationship is causal
2-
Case-control or cohort studies with a high risk of confounding, bias, or chance and a significant risk that the relationship is not causal
3
Nonanalytic studies (e.g., case reports, case series)
4
Expert opinion (e.g., narrative reviews, expert panel)
Grades of Recommendations
A
The recommendation is supported by good evidence.
B
The recommendation is supported by fair evidence.
C
The recommendation is supported by expert opinion only (e.g., published consensus document).
I
No recommendation can be made because the evidence is insufficient (i.e., evidence is lacking, of poor quality, or conflicting), and the balance of benefits and harms cannot be determined.
Good Practice Points (GPP)
Recommended practice based on the professional experience of the Guideline Development Team where there is no other evidence
