The four main themes identified were:
Decision-making and discussion of management options
Diagnosis of shoulder conditions
Discussion of prognosis
Giving and receiving reassurance
Theme 1: Decision-making and discussion of management options
Clinicians highlighted a number of considerations in the management of shoulder pain, such as the patient’s age, occupation, pain history and the impact of pain on their daily lives. However, they indicated that whilst these factors may influence their decisions, they routinely attempt to involve patients in decision-making through offering them a choice of treatments:
You need to take into account the patient demographics: age, sex, occupation and their presenting history, history of how the pain has started and presents…but I think it’s got to be a shared decision process between you and the patient as to which route they want to take…ultimately it’s patient choice. (Physiotherapist, male, 8 years practising)
This correlates with the views of some patients who reported making the final decision between treatments offered to them by the clinician:
P: He said I could leave it a while and have an injection, or I could refer you to physiotherapy. So, I thought I’d try physio.
Int: So it sounds like the doctor gave you some choice of which you preferred?
P: Yeah, it was my choice…I thought the physio might be a better long-term solution to the underlying problem rather than injection (Female patient, aged 64)
Clinicians reported that, in the absence of ‘red flag’ symptoms, in most cases they favoured initial conservative management, such as self-management advice, analgesia or referral to physiotherapy. However, some clinicians reported offering more invasive options, such as corticosteroid injection, at any early stage if the pain was significantly impacting the patient’s everyday life, or the patient was seeking short-term pain relief. This was the case in the following extract from a clinician-patient dyad:
So there was bicipital tendinosis, and [the patient] came back (for a follow-up consultation) and said the pain was still the same, it was still disturbing his sleep, what would be a quick fix. So we spoke about the pros and cons of injection, and he did have an injection…people do come with a pain, it’s affecting their sleep, it’s affecting their lifestyle. For people like this patient, who it does give them relief, then I think it’s a service that’s appreciated. (GP, female, 32 years practising)
The matched interview in this dyad shows consistency with the clinician’s account, in that the patient also highlighted the impact of the pain on his sleep as being his main concern. The patient reported having been hesitant about an injection, but expressed a strong preference for the decision about his treatment to be led by the GP:
It was a few days after when it started to occur and I couldn’t sleep. Oh, it was a nightmare. The whole of my arm ached…I couldn’t care less about medical stuff. I’ll leave that to the doctors. I’m not interested. All I want them to do is to treat me. So all I wanted, get rid of this pain in my arm, whatever way, let them tell me. I didn’t fancy an injection in my shoulder. I got home and thought, ‘What have I done?’. But do you know, from then on after that night it went easier. (Male patient, aged 64)
Clinicians similarly highlighted this preference of some patients not to be involved in their treatment decisions and instead wanting the clinician to take a directive approach, deferring to their clinical knowledge:
I do try and do shared management decision-making as much as possible with people and some patients are very amenable to that, and other people say ‘Well you’re the doctor, what should I do? What would you recommend?’. And then you think ‘Right okay, I think we probably should do this first and this next’. (Female GP, 3 years practising)
However, some patients’ views challenged the dichotomy between patient choice and clinician-led decision-making. They indicated that, even if they preferred the eventual decision to be taken by the clinician, they still wanted to engage in a form of shared decision-making involving discussion about available options and for the clinician to outline a potential treatment pathway. However, for many patients they reported that these discussions had not taken place:
He basically told me what it was [i.e. bursitis], felt along my shoulder and explained where things were and that there was the fluid sac or something, so basically that was it…if other treatment is available like physio or if I need another scan or anything like that, I would have liked to have discussed that because I don’t just want to be told, ‘oh well it’s this, learn to live with it’. (Female patient, aged 38)
Some patients also reported a lack of information from the clinician about why the recommended treatment was the most suitable and how it would treat their symptoms. They seemed to indicate a reluctance to raise these concerns during the consultation, but then felt dissatisfied following the consultation:
Basically the doctor asked me, would I like to have the steroid injections and I asked him ‘would it do me any good?’; which he said he thought it would, made my appointment…and that was basically the end of the consultation…when you come away you think, ‘what did I learn then?’. It was nothing, I learnt nothing, I didn’t know what the injection would do or why. (Male patient, aged 70)
Theme 2: Diagnosis of shoulder conditions
Receiving a diagnosis for their shoulder pain was important to patients, partly to reassure them that the pain was not caused by serious pathology (this is explored further in the ‘Giving and receiving reassurance’ theme, later), but also this was seen to be key to receiving the right management:
It’s nice to be told what it is [i.e. bursitis]…they could actually tell me what I can take to relieve the pain and not just keep saying ‘oh we don’t know, try this, it’s just something you are going to have to live with’…I know now that if it gets worse I can go to the doctors and they are aware of what it is and maybe how they can treat it. (Female patient, aged 38)
However, several patients reported that their GP either did not offer them a diagnosis or explanation of possible causes of their shoulder pain, or that they conveyed uncertainty. In many cases this resulted in the patient being referred for further investigation:
The GP thought that it was potentially something to do with the ligaments, just something’s worn out there and she thinks the bones are actually scratching on each other and that’s why it’s causing this sharp pain. It’s like the nerve’s been damaged there, that’s what she thinks has been going on…she will see on the ultrasound. She can’t say 100% but that’s what she's guessing. (Female patient, aged 39)
This diagnostic uncertainty was reflected in clinicians’ views. Many GPs reported lacking confidence in diagnosing shoulder conditions due to a perceived lack of skill in shoulder examination, leading them to commonly send patients for investigations such as an ultrasound scan:
I’m conscious that I do probably far too many ultrasounds…and I probably need to brush up on specific shoulder examination skills in order to be able to more specifically diagnose a specific tendonitis or bursitis or impingement or whatever, rather than just thinking ‘ooh it could be this that or the other’, without having to image; unless there were any red flags obviously. (GP, female. 32 years practising)
There was variation in the data, however, as all of the physiotherapists and a few GPs reported having greater confidence in diagnosing shoulder conditions. For many of these clinicians, providing a diagnosis was perceived to be a key part of their professional role:
If my role isn’t to diagnose people, then what am I doing? Of course it is…I’m perfectly happy in that part of my role. But I also am aware sadly of things like NICE [National Institute for Health and Care Excellence] guidance which seems a lot more investigation-focused, and I do think maybe some of my younger colleagues are more inclined to sort of hedge before making a definitive diagnosis, whereas I’m quite happy to put the code in, subacromial and move on. So yes, I think that’s an absolutely crucial part of my role. (GP, male, 28 years practising)
The majority of clinicians reported that during the initial stages of the COVID-19 pandemic, the need to conduct consultations remotely via telephone or video call had made diagnosing shoulder conditions more difficult. This was because in many cases physical contact with the patient was felt necessary for assessment and diagnosis. Additionally, examinations were limited by the patient’s ability to follow the clinician’s instructions in carrying out arm movements, as well as ensuring that these movements were captured on the screen:
To assess strength appropriately in different movements and different directions, you’re reliant on the patient having something suitable in their home to be able to do it for starters. Secondly, then to be able to position the phone in such a way that you can see them doing it, which sometimes isn’t the case. You also then need to be able to guide them with the technique…one of the things then you’re looking at with your rehab folk is trying to normalise that movement pattern. Sometimes that does require physical feedback, not just verbal feedback. So I think it’s a challenge to do over video. It’s not impossible, but it’s immensely difficult.
(Physiotherapist, male, 11 years practising)
This view was mirrored by patients, who felt that remote examinations were less thorough than in-person, hands-on examination, and also reported difficulty performing movements in line with the clinician’s instructions over video. As a result, patients reported feeling less confident when a diagnosis was provided:
You don’t get a full examination unless you meet the person I’d imagine. I think you can only do so much on the telephone or on video. I’m disappointed really that she was taking my [previous] diagnosis without examining me…I’ve had a video call from her and it was comical, absolutely comical. ‘Right put your phone in front of you, lift your arm up so I can see it’. [I replied] ‘Look, if I put my phone there I can’t see it, so I can’t see what you can see, so I can’t do the exercise’. (Male patient, aged 53)
Several patients reported receiving different diagnoses from different professionals, leading them to experience confusion. This is exemplified in the following clinician-patient dyad. The patient reported feelings of uncertainty, having been told by his GP that he had arthritis, but by another professional that he had subacromial shoulder pain (i.e. impingement):
They’ve been telling me different things. The first doctor who rang said it’s just arthritis…they referred me to physiotherapy…but the man who did my scan at the hospital told me it was quite a bad impingement. So I didn’t know which one to believe. (Male patient, aged 65)
The First Contact Practitioner (FCP) that the patient consulted with explained that, based on the patient’s X-ray and her examination, both diagnoses were indicated:
He had an X-ray of his shoulder which showed calcific rotator cuff tendonitis and subacromial bursitis and then the ultrasound showed some moderate OA (osteoarthritis) changes in his acromioclavicular joint. Normal long head of biceps, no rotator cuff tear but some thickening of the bursa which was felt likely to be representative of impingement. (FCP, female, 24 years practising)
Theme 3: Discussion of prognosis
Patients reported concerns about how long their shoulder pain might last and whether it could worsen or recur. In some cases, patients appeared to catastrophize about the future:
The pain is getting worse and there will be a point where I won’t be able to move my arm beyond that point [signals waist height]. And so that’s obviously going to limit my movement, which will impact my job severely. And who knows?” (Male patient, aged 46)
However, the majority of patients reported that their shoulder pain prognosis had not been discussed with the clinician. Many perceived that this was because the clinician was unlikely to know how their pain may progress, particularly if a diagnosis had not been established. Some patients appeared accepting of this uncertainty so long as a clear management plan was in place:
Int: Did the GP give you any idea about the future, whether it might be something that could be resolved, or…?
P: No, no, nothing, the GP didn’t really say, but nobody knows…she doesn’t really know exactly what's wrong with me, she can’t give me promises, because then I could be, ‘oh yeah, she said it’ll be fine, you know after this injection’, and then if it isn’t, I’d be like well ‘why did she say that?’ So I think it’s more not giving me false hope, she's like ‘okay, let’s see what we can do, we can offer you this and that, and if none of this works, we will try something else’. (Female patient, aged 49)
In contrast to this, other patients reported that they would have liked their prognosis to have been discussed in the consultation:
Int: Did they talk to you at all about the future outlook, the prognosis?
P: No, nothing of the sort. No, we didn’t talk about that.
Int: Is that something you’d liked to have discussed with the clinician?
P: Absolutely yeah. Managing expectations yeah, it’s a big thing isn’t it? Just to give me an idea if you’re going to get better or have I just got to live with it. (Male patient, aged 53)
Clinicians’ accounts showed discrepancy with these views, as all clinicians reported that they routinely discuss shoulder pain prognosis in consultations. The perceived this to be important for encouraging patients to engage with a management plan:
Int: Would you discuss with patients how their pain might progress?
P: Yeah all the time. I usually say, ‘right, for this sort of problem, from previous experiences and from the research out there it looks like it will take X amount of time to get better and if you engage with your physio programme the aim is to reduce that time scale of course’…just give them that advice on time scales and what we do next should they not improve within that timescale.
(Physiotherapist, female, 6 years practising)
Some clinicians reported a more cautious approach whereby they give patients a general idea of a timeframe for recovery rather than a specific prognosis. They also highlighted the importance of ensuring patients have realistic expectations about their recovery:
I want people to be realistic, so I don’t want them to expect it to get hugely better immediately and then be upset that it isn’t. So I will often say something like, ‘Shoulder problems can go on for months’ because I want them to have some realistic expectations. But I would then try and counter it by saying, ‘But if we do this and that and the other we’ll aim to make it feel better along the way and improve more quickly.’...because if you tell someone with a frozen shoulder the natural history is 18 months without any treatment, I mean that’s just depressing, but also realistic. So I kind of hedge my bets in the middle a little…what I don’t want them to do is ring me in a week and say, ‘It’s not better yet.’ So it’s just getting that balance really. (GP, female, 15 years practising)
The disparity in patients’ and clinicians’ accounts of discussing prognosis in consultations is exemplified in patient-clinician dyads. The following patient reported that neither diagnosis nor prognosis were discussed with his GP, and that his expectation was that his shoulder pain may never resolve:
The doctor didn’t actually say what he thought it was, he just thought the way to go forward was physiotherapy… my feeling is that I’ve probably got to live with it. I don’t really know what to expect. I’m not optimistic because I’m not 100% sure it’ll ever go. (Male patient, aged 74)
This contrasts with the GP’s account in which he reports having communicated to the patient a diagnosis of frozen shoulder and outlined the likely timeframe for recovery:
Int: Did you discuss [the pain condition] with him in the consultation?
P: Yes, yes. I always do, I always give explanation to patients that what I think it is, in lay terms, a frozen shoulder, and I gave him an idea of what it was about and then I referred him to physio…prognosis is vitally important. You need to give them an idea of timeframe because otherwise they’re not getting better. You’ve got to tell them the likelihood, how long it’s going to last before getting better, otherwise they come back and they don’t have faith in your management. (Male GP, 34 years practising)
Theme 4: Giving and receiving reassurance
Clinicians reported that patients commonly needed reassurance about the impact of shoulder pain on their function and daily activities. However, they felt that, unlike spinal pain, patients do not tend to have concerns about serious pathology related to their shoulder:
I don’t see necessarily that patients have that mentality and worrying about it being something nasty. However, I do see a lot more that they worry about whether they’re allowed to do certain things. So are they allowed to lift their arm if it’s painful? So I see a lot more worry about the pain or how long did it last rather than it being due to a non-MSK or a more sinister pathology.
(Physiotherapist, male, 11 years practising)
Patients’ accounts showed some discrepancy with these views, however, as patients reported concerns that something serious may be causing their shoulder pain, such as cancer, or a serious injury to the bones or ligaments. They therefore reported feeling reassured if they received a diagnosis:
Looking for exercises to help it, you go onto Google and it comes back you’ve got cancer straight away, isn’t it? Everything, ‘Oh yeah, points to cancer’… Once I knew it was tendonitis I was happy. I wasn’t happy, but I was happy if that makes sense.
(Male patient, aged 46)
The disparity between clinicians’ and patients’ views is reflected in the following dyad. The patient expressed concern that something serious may be wrong with his shoulder, but this appears to have either not been communicated, or not identified by the clinician:
You always think these things, is it some sort of bone cancer? Or, I’m not sure what can be done on ligaments or muscles that would be more serious, I’m not that familiar with things that go wrong in your shoulder. But yes you always wonder could it be something very serious, have I done some serious injury and not realised it? Is it some disease that’s eating away at my muscle or bone? (Male patient, aged 60)
I don’t think it was anxiety as such. It was more like he said, ‘I’d like not to have this pain please, if you can?’ rather than anything else. I certainly wouldn’t describe anxiety as a presenting feature with this chap. (GP, male, 24 years practising)
In some cases, when asked in interviews patients reported that they had not in fact expressed these concerns to their clinician:
P: When you get things like this you think the worst. I’m a bit of a worrier and I just think oh, cancer or something like that.
Int: Was she able to reassure you that it wasn’t?
P: No, no, no.
Int: Did you express those concerns to her?
P: Well I didn’t, no. I didn’t actually, no. (Female patient, aged 56)
Some patients who had not received a diagnosis for their shoulder pain suggested a tension whereby on the one hand they felt a sense of reassurance through having confidence in the expertise of their clinician, particularly where there was a strong therapeutic rapport, but at the same time they felt a lack of reassurance with regard to the cause of their pain:
She allows you time to go through everything and talks to you about everything, she’s a fabulous doctor. But in this situation she wouldn’t be able to tell me exactly what it was…so it was sort of reassuring but it wasn’t, at the same time.
(Female patient, aged 68)
A few GPs displayed a recognition of this tension, and highlighted the challenge they faced in attempting to reassure patients within the frame of diagnostic uncertainty. They reported addressing this through being honest about these uncertainties, and involving the patient in discussing management:
I think [the patient] was happy that the X-ray didn’t show any arthritis particularly, but I think he was then worried to say ‘Well what is it? What’s causing it?’. And I think that’s the difficult point where you say ‘Well it could be any number of things’… I believe very much so that we need to be honest with our patients if we don’t know the answer. What I often will say is ‘Look, these are the possibilities and these are the things I’m going to do to rule in or rule out those possibilities’. And I try and have a conversation about it and do shared management decision-making as much as possible. (Female GP, 6 years practising)
Clinicians also highlighted the need, in some instances, to provide reassurance about the relative value and risks of treatment options; for instance, reassuring patients that physiotherapy will not cause them harm or worsen their pain, even if the cause of pain is unclear:
Sometimes patients are nervous to go to physio if they don’t know what’s going on and we do find that’s sometimes a bit of barrier. Some of these people find it very reassuring to have something in terms of a scan or an X-ray that says ‘This is what’s happening’. Some people seem to worry that the physio will make things worse and I try to explain to a lot of patients that physio is very unlikely to make anything worse; chances are it’ll make probably make things better. (Male GP, 20 years practising)