Threshold

This policy does not apply to patients under the age of 18 years old, patients having treatment as part of the management of pain due to cancer or patients with inflammatory arthritis (rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis).

In all cases of shoulder pain, patients should be encouraged to self-manage their condition by actively participating in an MSK rehabilitation programme, where positive behavioural changes, such as exercise, weight loss, lifestyle adaptations and pacing, should be appropriately targeted. Self-management programmes, either individually or in groups, should emphasise the importance of these core treatments, especially exercise.

Consistent with both scientific evidence and local expert opinion, referral for ultrasound-guided corticosteroid for shoulder pain is not recommended for first line diagnosis and treatment. An appropriate Musculoskeletal (MSK) Pathway which facilitates the necessary stages of diagnosis and management of shoulder pain is available to support the implementation of this policy - Home/ClinicalInformation/Other/MusculoskeletalandOrthopaedic.aspx

In rare cases, for example, if patients need surgery, if there is uncertainty about the cause of shoulder pain or if physical differences make the usual treatment challenging, consultants may request US guided injections the benefits of this method of diagnosis or treatment should be recorded clearly in the patents records.

Referral for ultrasound-guided corticosteroid injections for  shoulders will only be funded by the CCG when at least one of the following criteria has been met and thoroughly documented: 

• History of severe trauma which would derange the normal architecture of the joint. 
• Failure of initial attempt of a corticosteroid injection due inability to identify landmarks. 
• Significant adverse effects associated with a landmark-guided injection, such as severe procedural pain.

Patients who have been referred to secondary care due to diagnostic uncertainty, and who are advised to have a corticosteroid injection, should not be referred for an ultrasound-guided injection in secondary care (unless the above criteria are met). 

In cases where the above criteria are met the CCG will fund up to 2 joint injections.


Cases for Individual Consideration

On a case to case basis, patients might be eligible for surgical intervention, in consideration of their exceptionality. The requesting clinician must provide information to support the case for being considered an exception, by submitting an individual funding request and will not be funded unless there are exceptional clinical circumstances. 

IFR Form required to be completed.