A survey of general practitioners’ assessment and management of shoulder pain: training and practice

Ian Ryans, Roland McKane, Siobhan McCann, Oonagh McNally, George Kernohan, Domhnall MacAuley

Research output: Contribution to journalArticlepeer-review


Introduction: Weaknesses in training of general practitioners (GPs) in musculoskeletal care havebeen identified. Little is known about methods of training GPs in shoulder pain management or theassessments they use in clinical practice. The aim of this study was to assess the effect of trainingmethods in shoulder pain management on GPs’ clinical practice.Methods: A validated, self-administered postal questionnaire on dealing with shoulder pain wassent to 1081 GPs.Results: Response rate was 48% (n = 520). The majority (82%) identified training at postgraduatemeetings, 17% had attended clinics and 11% attended musculoskeletal courses. Practitioners whohad been trained at clinics (odds ratio [OR] 17.5) and musculoskeletal courses (OR 8.2) were likelyto perform injections. Similarly, GPs’ confidence in shoulder examination was related to theirattendance at clinics (P = 0.019) and musculoskeletal courses (P <0.001) but not postgraduatemeetings. In their clinical examination, GPs found that assessing the active range of movement(ROM), passive ROM and painful arc were the most useful clinical findings and they foundcorticosteroid injection, NSAIDs and physiotherapy equally effective in treatment and each moreeffective than doing nothing.Conclusions: General practitioners’ confidence in assessment of shoulder pain and their likelihoodof performing injections was increased by training either at a clinic or specific musculoskeletalcourse but not by simply attending postgraduate meetings. They found the most useful methods ofassessment to be range of movement and painful arc, and considered injection, physiotherapy andNSAIDs as equally effective.
Original languageEnglish
Pages (from-to)179-185
JournalInternational Musculoskeletal Medicine
Issue number4
Publication statusPublished - Dec 2009

Bibliographical note

Reference text: References
1. Chard MD, Hazleman R, Hazleman BL, King RH, Reiss BB.
Shoulder disorders in the elderly: a community survey. Arthritis
Rheum 1991; 34: 766–769.
2. Pinney SJ, Regan WD. Educating medical students about
musculoskeletal problems. Are community needs reflected in the
curricula of Canadian medical schools? J Bone Joint Surg Am 2001;
83: 1317–1320.
3. Williams JR. The teaching of trauma and orthopaedic surgery to the
undergraduate in the United Kingdom. J Bone Joint Surg Br 2000;
82: 627–628.
4. Kay LJ, Deighton CM, Walker DJ, Hay EM. Undergraduate
rheumatology teaching in the UK: a survey of current practice and
changes since 1990. Arthritis Research Campaign Undergraduate
Working Party of the ARC Education Sub-committee.
Rheumatology (Oxford) 2000; 39: 800–803.
5. Craton N, Matheson GO. Training and clinical competency in
musculoskeletal medicine. Identifying the problem. Sports Med
1993; 15: 328–337.
6. Rasker JJ. Rheumatology in general practice. Br J Rheumatol 1995;
34: 494–497.
7. Booth A, Wise DI. General practice training in musculoskeletal
disorders. Br J Gen Pract 1990; 40: 390.
8. Lanyon P, Pope D, Croft P. Rheumatology education and
management skills in general practice: a national study of trainees.
Ann Rheum Dis 1995; 54: 735–739.
9. Glazier RH, Dalby DM, Badley EM, Hawker GA, Bell MJ,
Buchbinder R. Determinants of physician confidence in the primary
care management of musculoskeletal disorders. J Rheumatol 1996;
23: 351–356.
10. Gormley GJ, Corrigan M, Steele WK, Stevenson M, Taggart AJ.
Joint and soft tissue injections in the community: questionnaire
survey of general practitioners’ experiences and attitudes. Ann
Rheum Dis 2003; 62: 61–64.
11. Gormley GJ, Steele WK, Stevenson M et al. A randomised study of
two training programmes for general practitioners in the techniques
of shoulder injections. Ann Rheum Dis 2003; 62: 1005–1008.
12. de Winter AF, Jans MP, Scholten RJ, Deville W, van Schaardenburg
D, Bouter LM. Diagnostic classification of shoulder disorders:
interobserver agreement and determinants of disagreement. Ann
Rheum Dis 1999; 58: 272–277.
13. Bamji AN, Erhardt CC, Price TR, Williams PL. The painful
shoulder: can consultants agree? Br J Rheumatol 1996; 35:
14. Liesdek C, van der Windt DA, Koes BW, Bouter LM. Soft-tissue
disorders of the shoulder – a study of inter-observer agreement
between general practitioners and physiotherapists and an overview
of physiotherapeutic treatment. Physiotherapy 1997; 83: 12–17.
15. Pellecchia GL, Paolino J, Connell J. Intertester reliability of the
cyriax evaluation in assessing patients with shoulder pain. J Orthop
Sports Phys Ther 1996; 23: 34–38.
16. Winters JC, Groenier KH, Sobel JS, Arendzen HH, Meyboom-de
Jongh B. Classification of shoulder complaints in general practice by
means of cluster analysis. Arch Phys Med Rehabil 1997; 78:
17. Groenier KH, Winters JC, de Jong BM. Classification of shoulder
complaints in general practice by means of nonmetric
multidimensional scaling. Arch Phys Med Rehabil 2003; 84: 812–817.
18. Buchbinder R, Green S, Youd JM. Corticosteroid injections for
shoulder pain. Cochrane Database Syst Rev 2003; (1): CD004016.
19. Green S, Buchbinder R, Glazier R, Forbes A. Systematic review of
randomised controlled trials of interventions for painful shoulder:
selection criteria, outcome assessment, and efficacy. BMJ 1998; 316:
20. Green S, Buchbinder R, Hetrick S. Physiotherapy interventions for
shoulder pain. Cochrane Database System Rev 2003; (2): CD004258.
21. van der Heijden GJ, van der Windt DA, de Winter AF.
Physiotherapy for patients with soft tissue shoulder disorders: a
systematic review of randomised clinical trials. BMJ 1997; 315:
22. van der Heijden GJ, van der Windt DA, Kleijnen J, Koes BW, Bouter
LM. Steroid injections for shoulder disorders: a systematic review of
randomized clinical trials. Br J Gen Pract 1996; 46: 309–316.
23. O’Reilly D, Gilliland A, Steele K, Kelly C. Reasons for patient
removals: results of a survey of 1005 GPs in Northern Ireland. Br J
Gen Pract 2001; 51: 661–663.
24. Morris CJ, Cantrill JA, Weiss MC. GP survey response rate: a
miscellany of influencing factors. Fam Pract 2001; 18: 454–456.
25. McKenna C, Bojke L, Manca A et al. Shoulder acute pain in primary
health care: is retraining GPs effective? The SAPPHIRE randomized
trial: a cost-effectiveness analysis. Rheumatology (Oxford) 2009; 48:
26. Watson J, Helliwell P, Morton V et al. Shoulder acute pain in
primary healthcare: is retraining effective for GP principals?
SAPPHIRE–a randomized controlled trial. Rheumatology (Oxford)
2008; 47: 1795–1802.
27. Lasch KE, Wilkes G, Lee J, Blanchard R. Is hands-on experience
more effective than didactic workshops in postgraduate cancer pain
education? J Cancer Educ 2000; 15: 218–222.
28. Aabakken L, Osnes M, Rosseland AR et al. Hands-on endoscopy
training: an evaluation of the SADE endoscopy course.
Scandinavian Association of Digestive Endoscopy. Endoscopy 1995;
27: 66–69.
29. Olinger A, Pistorius G, Lindemann W, Vollmar B, Hildebrandt U,
Menger MD. Effectiveness of a hands-on training course for
laparoscopic spine surgery in a porcine model. Surg Endosc 1999; 13:
30. Johansson K, Adolfsson L, Foldevi M. Attitudes toward
management of patients with subacromial pain in Swedish primary
care. Fam Pract 1999; 16: 233–237.
31. Croft P, Pope D, Boswell R, Rigby A, Silman A. Observer variability
in measuring elevation and external rotation of the shoulder.
Primary Care Rheumatology Society Shoulder Study Group. Br J
Rheumatol 1994; 33: 942–946.
32. Pope DP, Croft PR, Pritchard CM, Macfarlane GJ, Silman AJ. The
frequency of restricted range of movement in individuals with selfreported
shoulder pain: results from a population-based survey. Br J
Rheumatol 1996; 35: 1137–1141.
33. Leroux JL, Thomas E, Bonnel F, Blotman F. Diagnostic value of
clinical tests for shoulder impingement syndrome. Rev Rhum
(English edn) 1995; 62: 423–428.
34. Johansson K, Oberg B, Adolfsson L, Foldevi M. A combination of
systematic review and clinicians’ beliefs in interventions for
subacromial pain. Br J Gen Pract 2002; 52: 145–152.
35. Ekeberg OM, Bautz-Holter E, Tveita EK, Juel NG, Kvalheim S,
Brox JI. Subacromial ultrasound guided or systemic steroid injection
for rotator cuff disease: randomised double blind study. BMJ 2009;
338: a3112.


  • primary care
  • training
  • shoulder pain
  • corticosteroid injection


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