| History and physical exam |
Focused history and exam
Search for red flags (e.g., for tumor, infection, angina) (C)
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| Patient education |
Patient education regarding condition or disorder, expectations of treatment, side effects, etc. (D) |
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| Medication (See Chapter 3 in the original guideline document) |
Acetaminophen (C)
Non-steroidal anti-inflammatory drugs (NSAIDs) (B)
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Opioids, short course (C) |
Use of opioids for more than 2 weeks (C)
Muscle relaxants (D)
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| Physical treatment methods, activities and exercise |
Maintain activities of other parts of body while recovering (D)
Maintain passive range of motion of the shoulder with pendulum exercises and wall crawl (D)
Treat initially with strengthening or stabilization exercises for impingement syndrome, rotator cuff tear, instability, and recurrent dislocation (C, D)
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At-home applications of heat or cold packs to aid exercises (D)
Short course of supervised exercise instruction by a therapist (D)
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Passive modalities by therapist (unless accompanied by teaching the patient exercises to be carried out at home) (D) |
| Injections |
Two or three sub-acromial injections of local anesthetic and cortisone preparation over an extended period as part of an exercise rehabilitation program to treat rotator cuff inflammation, impingement syndrome, or small tears (C, D)
Diagnostic lidocaine injections to distinguish pain sources in the shoulder area (e.g., impingement) (D)
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Prolonged or frequent use of cortisone injections into the sub-acromial space or the shoulder joint (D) |
| Rest and immobilization |
Brief use of a sling for severe shoulder pain (1 to 2 days), with pendulum exercises to prevent stiffness in cases of rotator cuff conditions (D)
Three weeks use, or less, of a sling after an initial shoulder dislocation and reduction (C)
Same for acromioclavicular (AC) separations or severe sprains (D)
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Prolonged use of a sling only for symptom control (D) |
| Detection of physiologic abnormalities |
Rarely, nerve conduction time of the suprascapular nerve for cases of severe cuff weakness unaccompanied by signs of a rotator cuff tear (D) |
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Electromyography (EMG) or nerve conduction velocity (NCV) studies as part of a shoulder evaluation for usual diagnoses (D) |
| Radiography |
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For acute AC joint separations, stress films (views of both shoulders, with and without patient holding 15-lb weights) (D) |
Routine radiographs for shoulder complaints before 4 to 6 weeks of conservative treatment (D)
Stress films for instability (D)
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| Other imaging procedures |
Magnetic resonance imaging (MRI) for preoperative evaluation of partial-thickness or large full-thickness rotator cuff tears (C, D) |
Arthrography for preoperative evaluation of small full-thickness tears (C)
Bone scan for detection of AC joint arthritis (D)
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Routine MRI or arthrography for evaluation without surgical indications (D)
Ultrasonography for evaluation of rotator cuff (C)
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| Surgical considerations |
Anterior repair for recurrent dislocation after 2 to 3 dislocations (D)
Resection of outer clavicle for chronic disabling AC joint pain after conservative care of acute separation (C)
Rotator cuff repair after firm diagnosis is made and rehabilitation efforts have failed (D)
Capsular shift surgery for disabling instability (D)
Subacromial decompression after failure of non-operative care (C)
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Anterior repair for initial shoulder dislocation (C)
Acute repair of AC separation (C)
Acute repair of rotator cuff tears, except for massive acute tears (C)
Surgery for recurrent dislocation of instability before rehabilitation efforts (C)
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