1. Graph to show the number of patients receiving management options
Audit to evaluate the management of rotator cuff tendinopathy and shoulder impingement in general practice. Linda Evans, University of Leeds
Introduction
NICE Clinical Knowledge Summaries are designed to aid management of common conditions in primary care. The aim of this audit was to determine if the summary for rotator cuff tendinopathy is up to date and is implemented in primary care, or is there a need for further training?
The audit took place in a suburban GP practice with 10,500 patients and 12 general practitioners.
A) Literature review results
1) Postural retraining relieves shoulder pain in impingement2 .
2) Exercise therapy is as effective as surgery for rotator cuff tendinopathy(RCT)3 and should be used first line4.
3) Steroid injections without ultrasound guidance were as safe and had similar outcomes as under US guidance but were more cost-effective5.
4) X rays are not indicated in RCT or shoulder impingement (SI).
5) Current NICE guidance does not consider the use of imaging1.
Conclusions
1) NICE guidance may not provide practitioners with the most current gold standard treatment of shoulder impingement (SI) and rotator cuff tendinopathy (RCT).
2) There were fewer patients presenting with shoulder pain than expected and of these few given a code of (SI) or (RCT). This could demonstrate a lack of understanding of these conditions in general practice. Also RCT and SI are connected; SI is a symptom of tendinopathy 6. Some patients with ‘shoulder pain’ may have RCT, but an uncertainty of diagnosis may lead to incorrect coding.
3) RCT and SI management is still poorly understood with 8 inappropriate radiological referrals which can be costly and potentially harmful.
4) RCT and SI have a high rate of reattendance, which may be contributed to by a lack of understanding.
5) Analgesia could be more cheaply obtained over the counter resulting in lower levels of prescription than expected.
6) Postural retraining, whilst recommended, may not be documented as information given by physiotherapists and doctors.
Aims
To determine the gold standard for management of rotator cuff tendinopathy tendinopathy (RCT) and shoulder impingement (SI).
To evaluate the management of RCT and SI in general practice.
To make recommendations for improving the management of RCT and SI based on the current gold standards.
Graph to show the number of patients receiving management options
Number of patients
Methodology
A) Literature Review of the management of rotator cuff tendinopathy and shoulder impingement.
B) Retrospective audit from systm one
Dates: January 2013-June 2015
Parameters: ‘shoulder pain’ ‘rotator cuff’ ‘shoulder impingement’
Age range: 18-40
Management
Recommendations for future research
Does re-attendance reflect failure of conservative management or is it a result of the nature of the injury?
Would practitioners benefit from further training and better guidance?
How confident do practitioners feel in diagnosing and managing RCT and SI?
Current NICE Guidance1
Stage 1: Advise modification of activities that exacerbate symptoms (such as reaching overhead ).
Offer analgesia- paracetamol with or without codeine, or an oral nonsteroidal anti-inflammatory drug (NSAID, e.g. ibuprofen).
Stage 2: Refer to physiotherapy (for advice on an exercise regimen and consideration of other therapies) if self-care measures and analgesia are not effective.
Stage 3: Consider a subacromial corticosteroid injection if the person has a poor response to initial treatment after several weeks and requires further pain relief, or has very limited function because of pain.
B) Audit Results
Of the 79 patients with shoulder pain 14  were coded on systm one as having rotator cuff problems and a further 11 with shoulder impingement.
71% of patients coded with RCT were referred to physiotherapy and 55% of SI  
The most popular physiotherapy technique was ROM exercise.
Ibuprofen was the most prescribed mediation and 44% of this was topical
7 patients with RCT or SI were referred for an x ray and 1 for MRI.
References
1.Nice Clinical Reference Summary Shoulder Pain. NICE Guidelines. London: NICE Available at:
2. Struyf F, Nijs J, Mottram S, et al. British Journal of Sports Medicine. 2014;48:
3. Tolipoulos P, Desmeules F, Boudreault J, Roy J-S, Frémont P, MacDermid JC, Dionne CE.Efficacy of surgery for rotator cuff tendinopathy: a systematic review. Clin Rheumatology.2014;33:
4. Littlewood C, Ashton J, Chance-Larsen K, May S, Sturrock B. Exercise for rotator cuff tendinopathy:a systematic review. Physiotherapy 2012;98:
5. Bloom JE, Rischin A, Johnston RV, Buchbinder R. Image-guided versus blind glucocorticoid injection for shoulder pain. Cochrane Database of Systematic Reviews. 2012, Issue 8. Art. No.:CD DOI / CD pub2.
6. Brukner P and Khan K Brukner & Khan’s Clinical Sports Medicine. 4th ed. Australia: McGraw Hill .