Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 27 Aug 2026Clinical review pending
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Acute destructive pain needs urgent exclusion
A suddenly hot, swollen or rapidly painful shoulder, systemic illness, recent bacteraemia or injection, trauma, neurovascular change or unexpectedly rapid radiographic destruction may represent sepsis, fracture, dislocation, neuropathic arthropathy or malignancy rather than ordinary osteoarthritis.
Action: Assess observations and the whole limb, use urgent radiographs after trauma, obtain inflammatory tests and arrange same-day joint aspiration and orthopaedic review for suspected infection, and investigate rapid destruction or tumour without delaying behind a chronic osteoarthritis label.
Synopsis
Diagnose symptomatic glenohumeral osteoarthritis by combining mechanical symptoms, passive restriction and radiographs, exclude urgent destructive disease, deliver person-centred core care, and refer for arthroplasty according to impact rather than imaging alone.
Typical disease produces deep activity-related shoulder pain, night discomfort, crepitus and progressive restriction of both active and passive glenohumeral movement.
First-line investigation when structural confirmation is needed is plain radiography with true anteroposterior and axillary or equivalent orthogonal views; correlate change with symptoms and function.
Do not attribute a hot acute shoulder, rapid collapse or constitutional pain to known osteoarthritis without excluding infection, fracture, osteonecrosis, neuropathic disease and malignancy.
Key red flags
Fever, warmth, effusion and intense pain with small passive movements requires urgent septic arthritis assessment and aspiration before any steroid injection.
Investigation priorities
01
First-line clinical and functional assessmentFirst stepFirst line
Establish whether pain and passive restriction arise from the glenohumeral joint and quantify quality-of-life impact.
02
First-line structural imaging with radiographsFirst line
Confirm osteoarthritis, identify humeral and glenoid pattern and exclude fracture or gross destructive disease.
Management branches
First-lineConfirm concordant joint disease
Deep mechanical pain and passive restriction suggest glenohumeral osteoarthritis without an acute red flag.
Document sleep, dressing, grooming, work, mobility-aid use and goals and examine cuff, neck, acromioclavicular joint and neurology.
Obtain orthogonal radiographs when diagnosis or treatment planning requires structural confirmation.
Key medicines
Topical diclofenac gelApply 2–4 g of diclofenac 1.16% gel to the painful shoulder at each use, up to three or four applications per day for a limited trial and never above the licensed product maximum.
Oral NSAID plus proton-pump inhibitorWhen suitable, use naproxen 250–500 mg orally twice daily with food at the lowest effective dose for the shortest period and add omeprazole 20 mg orally once daily while treatment continues when indicated.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.