Shoulder Assessment Clinical Pathways - Section 1 - Clinical Pathway Algorithm for Shoulder Pain

Oct 13, 2026

Clinical pathways for shoulder pain outline a structured approach for clinicians across primary care assessment, triage, and confirmation of the shoulder problem. The guidance emphasizes early, non-operative management for appropriate patients, minimizing unnecessary diagnostic imaging, improving the suitability of surgical referrals, and reducing surgical consultation waiting lists. Content includes stepwise history-taking, identification of red flags requiring urgent referral, and decision points for referral versus alternative pathway when neurological or neck-related symptoms are reproduced.

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SECTION 1. CLINICAL PATHWAY ALGORITHM FOR SHOULDER PAIN

STEP 1: Primary Care Assessment

STEP 2: Triage

STEP 3: Confirm Shoulder Problem

SECTION 2. HISTORY-TAKING

PATIENT PROFILE

RED FLAGS

ADDITIONAL CONSIDERATIONS

SECTION 3. PHYSICAL EXAMINATION

STEP 1: Inspection and positioning

STEP 2: Rule out cervical spine pathology

STEP 3: Shoulder ROM and strength testing

| Shoulder Assessment Clinical Pathways
Release Date: May 2022
Version 4 – Revised July 2023
S1 . Algorithm for Shoulder Pain | | | --- | --- | | Quick links: |

Appendix 1. Special Test Guide

Appendix 2. Shoulder One Pager
| | These pathways will help guide clinicians with appropriate procedures for patient management, investigations, and referrals.
The purpose of these pathways is to:
• initiate early, non-operative management for suitable patients;
• reduce unnecessary diagnostic imaging;
• increase the appropriateness of surgical referrals; and,
• reduce waiting lists for surgical consult.
| | Shoulder Assessment Clinical Pathways SECTION 1. CLINICAL PATHWAY ALGORITHM FOR SHOULDER PAIN | STEP 1: Primary Care Assessment | | | --- | --- | | Perform HISTORY-TAKING
See Section 2: History-taking | Perform PHYSICAL EXAMINATION
See Section 3: Physical examination | STEP 2: Triage Q 1. Were RED FLAGS identified in STEP 1? NO Proceed to STEP 3. YES REFER FOR URGENT CARE See Section 2: RED FLAGS | STEP 3: Confirm Shoulder Problem | | --- | | Q 2. Were pain and neurological symptoms reproduced with neck movement?(See Section 3: Physical examination) | NO This is likely a shoulder problem. Proceed to STEP 4. YES This is likely not a shoulder problem. • If a neck problem is suspected, ALTERNATIVE PATHWAY IS REQUIRED. These pathways will help guide appropriate procedures for patient management, investigations, and referrals. The purpose of this guideline is to initiate early, non-operative management for suitable patients, reduce unnecessary diagnostic imaging, increase appropriateness of surgical referrals, and reduce waiting lists for surgical consult. Page 2 of 16 Last revised: 07/2023 Back to Top | Shoulder Assessment Clinical Pathways
SECTION 2. HISTORY-TAKING | | --- | | PATIENT PROFILE | | Age: Sex: Occupation: Dominant Hand:

Q 1. When did you first notice you had a problem with your shoulder?

Q 2. Is your shoulder problem the result of a specific injury?
If YES, describe how you injured your shoulder in as much detail as possible.
If NO, describe the activity that provokes pain.

Q 3. Do you have pain in your shoulder?
If YES, proceed to Question 4.
If NO, proceed to Question 5.
Q 4. Can you characterize your pain? • Where in your shoulder do you feel the most pain?
• How long have you been symptomatic ([i.e. date](i.e. date))?
• What is your pain severity?
• Is there pain during specific activity?
• Is there presence of night pain?
• Is there pain at rest?
• Does anything aggravate the pain? If yes, specify.
• Does anything help to relieve the pain? If yes, specify.

Q 5. Does your shoulder feel stiff?

RED FLAGS
Red flags identified during primary care assessment require urgent secondary care referral. INDICATION REFERRAL Unreduced
dislocation Obvious deformity; constant or progressive pain Same day emergency referral to ED via phone call Fracture Obvious deformity; constant or progressive pain Same day emergency referral to ED via phone call Infection or septic arthritis Systemically unwell; fever; unexplained swelling; pain unrelated to activity; pain not relieved with rest Same day emergency referral to ED via phone call Tumour History of cancer; night sweats; unremitting night pain; unexplained, unintentional, sudden weight loss; unexplained deformity or mass; acute onset with no identifiable cause; pain unrelated to activity; pain not relieved with rest Urgent referral to orthopaedic oncology surgeon within 1 week via phone call Large /massive acute, traumatic rotator cuff tear Unable to lift arm (forward flexion) to 90 degrees Urgent referral to orthopaedic surgeon within 1 week via phone call *ED: emergency department
ADDITONAL CONSIDERATIONS
If any of the following are identified during the primary care assessment, the patient ma

FAQs

What is the overall purpose of the Shoulder Assessment Clinical Pathways?

The pathways guide clinicians on appropriate patient management, investigations, and referrals. They aim to support early non-operative management for suitable patients, reduce unnecessary diagnostic imaging, improve appropriateness of surgical referrals, and reduce waiting lists for surgical consult.

Which findings trigger urgent referral during primary care assessment?

Red flags identified in primary care assessment require urgent secondary care referral. Examples listed include unreduced dislocation, fracture, infection or septic arthritis, tumour-related features, and large/massive acute traumatic rotator cuff tear, with specified escalation timing.

When is an alternative pathway required?

An alternative pathway is required if pain and neurological symptoms are reproduced with neck movement during triage, or if neck movement reproduces the pain during cervical spine rule-out in physical examination. The document also specifies alternative pathway measures for certain additional considerations.

Oct 13, 2026

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