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msk.shoulder-pain.core.v1PRODUCTION
msk.shoulder-pain.core.v1

Shoulder pain / rotator-cuff disorders

rheumatologysubacutechronicadult
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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Shoulder pain is a region, not a diagnosis; phenotype-first; the rotator-cuff spectrum (tendinopathy → partial → full tear) dominates, with adhesive capsulitis / instability / AC-OA / calcific / referred as the MECE alternatives (JOSPT 2022 Lafrance)

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Scope framed: cuff-spectrum-dominant region with MECE phenotype alternatives

Patient inputs (13)

Pre-test prior shifts sharply with age — atraumatic full-thickness cuff tears rise from ~10% (<60 y) to >30% (>70 y), often asymptomatic; instability favours <30 y, adhesive capsulitis 40–60 y (JOSPT 2022 Lafrance)

Diabetes raises adhesive-capsulitis risk (~5× OR; ~13% vs ~4% prevalence) and drives steroid-glycaemia caution; thyroid disease is an additional capsulitis association (Zreik meta-analysis)

eGFR / peptic-ulcer / cardiovascular status gates NSAID use and dose (calc.ckd_epi_2021 on the renal branch) (JOSPT 2022 — pharm is adjunct only)

Subacute vs chronic banding sets expected recovery trajectory and the imaging/surgery T_test (JOSPT 2022 Lafrance)

Loss of PASSIVE external rotation (≥50% vs contralateral) is the decisive MECE pivot for adhesive capsulitis vs the cuff spectrum (UK FROST Rangan 2020)

Acute trauma + sudden weakness flags an acute full-thickness tear in an active patient — the one time-critical surgical window (JOSPT 2022 Lafrance; AAOS 2019)

Fever / systemic illness with a hot swollen shoulder = septic arthritis screen (mandatory aspiration) (JOSPT 2022 Lafrance)

Dermatomal arm pain / Spurling-positive neck, weight loss / night pain / smoking (Pancoast, malignancy), patchy weakness after viral prodrome (Parsonage-Turner) — referred / cannot-miss screen (AAOS 2019; JOSPT 2022)

Ultrasound or MRI ONLY when the result changes management (surgical-candidate / acute traumatic full-thickness tear, instability/labrum) — the encoded T_test threshold (JOSPT 2022 Lafrance)

Overhead occupation / athlete shifts pre-test prior toward cuff/instability and drives the return-to-work / return-to-sport plan (JOSPT 2022 Lafrance return-to-work module)

Recurrent instability count drives the instability-recurrence risk and surgical-stabilisation referral (AAOS 2019)

First-line imaging for trauma / OA / calcific deposit / instability bone lesions — NOT routine for typical subacromial pain (JOSPT 2022 Lafrance; AAOS 2019)

CRP/ESR/WCC ONLY to exclude inflammatory arthropathy / septic joint — not routine in mechanical shoulder pain (JOSPT 2022 Lafrance)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (13)

13 need judgement
  • informationallife_threateningseptic_glenohumeral_joint
    Fever / systemic illness with a hot, swollen, exquisitely painful shoulder and global motion loss (JOSPT 2022 Lafrance)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereacute_traumatic_full_thickness_tear_surgical_window
    Acute trauma (fall on outstretched arm / forced abduction) followed by sudden cuff weakness in a younger active patient — time-critical surgical window (JOSPT 2022 Lafrance; Cochrane 2019 PMID 31813166)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverehigh_probability_full_thickness_tear_composite
    Full-thickness-tear composite reaching a STRONG rule-IN LR+: the Gwark & Park 2019 multivariable model (age ≥67 + subscapularis tear + Patte retraction ≥2 + hs-CRP >1 mg/L + pain VAS ≥7) gives LR+ 19.07 / post-test 96% (PMID 31699076); chained with a lag-sign cluster that PERSISTS after a subacromial-lidocaine block (specificity/LR rises post-block — Bak 2010 PMID 20511030 Level-I) in the trauma/age-conditioned prior, the wired composite LR+ exceeds 20. The cluster LR is computed with conditional dependence, NOT as the product of the singles (Park 2005 PMID 15995110: painful-arc+drop-arm+infraspinatus → post-test 91% for a full-thickness tear from a defined cohort prior)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveremalignancy_or_pancoast_red_flag
    Night pain, unexplained weight loss, smoking history, fixed/firm mass or constant non-mechanical pain (primary bone tumour, metastasis, Pancoast apical lung tumour) (AAOS 2019)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereparsonage_turner_neuralgic_amyotrophy
    Abrupt severe shoulder/arm pain followed within days–weeks by patchy motor weakness/wasting, often after a viral illness or immunisation (AAOS 2019)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverereferred_cervical_or_cardiac_lookalike
    Dermatomal arm pain with positive Spurling / neck-driven symptoms, OR exertional / non-positional pain with cardiac risk — non-shoulder source (AAOS 2019; JOSPT 2022 Lafrance)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateadhesive_capsulitis_passive_ER_loss_pivot
    Progressive global stiffness with ≥50% loss of PASSIVE external rotation vs the contralateral side — the decisive MECE pivot for frozen shoulder (UK FROST Rangan 2020 PMID 33010843)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderaterecurrent_glenohumeral_instability
    Recurrent subluxation/dislocation, especially younger contact-sport patient with high recurrence risk (AAOS 2019)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatensaid_comorbidity_risk
    Reduced eGFR (CKD-EPI 2021 race-neutral), active peptic-ulcer disease, or significant cardiovascular disease in a patient for whom an NSAID adjunct is considered (JOSPT 2022 Lafrance)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepregnancy_or_lactation_analgesia_branch
    Pregnant or breastfeeding patient with mechanical shoulder pain requiring analgesic adjunct (special-population branch)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatehepatic_impairment_analgesia_branch
    Chronic liver disease (Child-Pugh B/C) in a patient needing an analgesic adjunct for shoulder pain (special-population branch)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderategeriatric_polypharmacy_deprescribing_branch
    Older adult (≥65 y) on chronic NSAID for shoulder pain, or with an incidental degenerative cuff tear, where STOPP/START flags NSAID deprescribing (special-population branch)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateadolescent_or_pediatric_shoulder_exclusion
    Patient under ~18 y with shoulder pain — atraumatic degenerative cuff disease is not the working model; instability / physeal (Little-League shoulder) / referred causes dominate (age-cutoff special-population branch)
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Subacromial / rotator-cuff symptom-control ladder (exercise-first; NSAID + single transient injection adjuncts; surgical-referral gating) (JOSPT 2022 Lafrance; CSAW Beard 2018; Cochrane 2019)
axis: subacromial_rotator_cuff_symptom_ladderstep 1 - Step 1 — Education + progressive task-oriented exercise (FIRST-LINE)
Selected step "Step 1 — Education + progressive task-oriented exercise (FIRST-LINE)" — Subacromial pain / rotator-cuff tendinopathy / degenerative partial or full-thickness tear without an acute traumatic surgical window
  • education + activity modification
    first line
    patient_education
    triggers: any_cuff_spectrum_phenotype
    JOSPT 2022 Lafrance — reassurance, expectation-setting (slow recovery over weeks–months), de-emphasise structural labels; degenerative tears are common and often asymptomatic in older adults
  • progressive task-oriented rotator-cuff & scapular exercise programme
    first line
    therapeutic_exercise
    triggers: cuff_tendinopathy, subacromial_pain, degenerative_cuff_tear
    JOSPT 2022 Lafrance core recommendation; Steuri BJSM 2017 PMID 28588109 — exercise improves pain & function vs no/sham; CSAW (PMID 29169668) & FIMPACT 5-y (PMID 33020137) — exercise equals surgery; Cochrane 2019 (PMID 31813166) — repair little/no clinically important benefit over exercise for degenerative tears

outpatient playbook — drug actions (4)

  1. 1. education + progressive task-oriented exercise
    structured programme, progressive load • physiotherapy • ongoing, reviewed q6–12 wk
    trigger: Any cuff-spectrum phenotype without an acute surgical window
    First-line; equals surgery for subacromial pain / degenerative tears (CSAW PMID 29169668; FIMPACT PMID 33020137; Cochrane 2019 PMID 31813166)
  2. 2. naproxen (or ibuprofen)
    naproxen 250–500 mg BID / ibuprofen 400 mg TID with food • PO • BID–TID, shortest course
    trigger: Pain limiting exercise participation; eGFR≥30, no PUD/severe CVD
    Short-term NSAID adjunct (JOSPT 2022 Lafrance)
  3. 3. acetaminophen
    500–1000 mg q6h PRN (≤3 g/day if hepatic risk) • PO • q6h PRN
    trigger: NSAID contraindicated (CKD/PUD/CVD)
    Weak analgesic adjunct / NSAID-sparing (JOSPT 2022 Lafrance)
  4. 4. methylprednisolone (or triamcinolone — rxcui omitted)
    40 mg subacromial/intra-articular, single • subacromial / intra-articular • single; ceiling ≤2–3 per shoulder
    trigger: Refractory pain limiting rehab; frozen-shoulder freezing phase
    Transient benefit only; image guidance not required (Bloom Cochrane 2012 PMID 22895984); frozen shoulder per UK FROST PMID 33010843

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Lateral / deltoid shoulder pain worse with overhead activity (subacromial / cuff) (JOSPT 2022 Lafrance); Painful mid-range arc ± cuff weakness (rotator-cuff spectrum) (JOSPT 2022 Lafrance); Progressive global stiffness with loss of passive external rotation (adhesive capsulitis) (UK FROST Rangan 2020).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Shoulder pain / rotator-cuff disorders** (msk.shoulder-pain.core.v1).
Phenotype framing: MECE: rotator-cuff tendinopathy vs partial-thickness vs full-thickness tear vs subacromial (impingement) pain vs adhesive capsulitis (PASSIVE ER loss pivot) vs glenohumeral instability vs AC-joint OA vs calcific tendinitis vs referred (cervical radiculopathy, cardiac, diaphragmatic). PIVOTS: (1) capsulitis vs cuff = global PASSIVE ER loss (capsulitis) vs ACTIVE>passive loss (cuff) — pivot interpreted against the diabetes-conditioned prior; (2) shoulder vs neck = provocative shoulder tests negative + pain reproduced by neck/Spurling → route msk.mechanical-neck-pain.core.v1 (carryover: neck-ROM, Spurling, dermatomal/myotomal map); (3) regional vs polyarticular inflammatory = if a hot/swollen shoulder is part of a symmetric small-joint synovitis with morning stiffness >1 h / raised CRP-ESR → route rheum.rheumatoid-arthritis.core.v1 (carryover: joint count, inflammatory markers, RF/anti-CCP intent); (4) mechanical pain vs central sensitisation = if shoulder pain sits within a widespread-pain / non-anatomic-tenderness pattern with normal structural workup → consider co-existent central pain and route msk.fibromyalgia.core.v1 (carryover: widespread-pain index, sleep, somatic-symptom burden); (5) chronic cuff degeneration vs degenerative glenohumeral/AC OA → msk.osteoarthritis.core.v1; (6) load-related cuff tendinopathy as a regional instance of the shared progressive-loading model → msk.tendinopathy.core.v1. Co-existence handled: degenerative cuff tear is frequently INCIDENTAL in the elderly (prior-conditioned — do not over-attribute); capsulitis can co-exist with cuff disease; cervicobrachial pain can co-exist with cuff disease (treat dominant generator, re-screen the other) (UK FROST Rangan 2020 PMID 33010843; JOSPT 2022 Lafrance PMID 35881707; AAOS 2019)
Scope: Shoulder pain is a region, not a diagnosis; phenotype-first; the rotator-cuff spectrum (tendinopathy → partial → full tear) dominates, with adhesive capsulitis / instability / AC-OA / calcific / referred as the MECE alternatives (JOSPT 2022 Lafrance)

No severity triggers fired against current inputs.

Plan

Regimen axis: **Subacromial / rotator-cuff symptom-control ladder (exercise-first; NSAID + single transient injection adjuncts; surgical-referral gating) (JOSPT 2022 Lafrance; CSAW Beard 2018; Cochrane 2019)** — step "Step 1 — Education + progressive task-oriented exercise (FIRST-LINE)".
1. education + activity modification (patient_education, first line) — JOSPT 2022 Lafrance — reassurance, expectation-setting (slow recovery over weeks–months), de-emphasise structural labels; degenerative tears are common and often asymptomatic in older adults
2. progressive task-oriented rotator-cuff & scapular exercise programme (therapeutic_exercise, first line) — JOSPT 2022 Lafrance core recommendation; Steuri BJSM 2017 PMID 28588109 — exercise improves pain & function vs no/sham; CSAW (PMID 29169668) & FIMPACT 5-y (PMID 33020137) — exercise equals surgery; Cochrane 2019 (PMID 31813166) — repair little/no clinically important benefit over exercise for degenerative tears

Setting playbook (outpatient) — Phenotype the shoulder, screen the cannot-miss / surgical-window causes, deliver education + progressive exercise as first-line, gate pharm/injection adjuncts by comorbidity, and refer surgically only by criteria/timing (JOSPT 2022 Lafrance; AAOS 2019; UK FROST Rangan 2020)
3. education + progressive task-oriented exercise structured programme, progressive load physiotherapy ongoing, reviewed q6–12 wk — Any cuff-spectrum phenotype without an acute surgical window (First-line; equals surgery for subacromial pain / degenerative tears (CSAW PMID 29169668; FIMPACT PMID 33020137; Cochrane 2019 PMID 31813166))
4. naproxen (or ibuprofen) naproxen 250–500 mg BID / ibuprofen 400 mg TID with food PO BID–TID, shortest course — Pain limiting exercise participation; eGFR≥30, no PUD/severe CVD (Short-term NSAID adjunct (JOSPT 2022 Lafrance))
5. acetaminophen 500–1000 mg q6h PRN (≤3 g/day if hepatic risk) PO q6h PRN — NSAID contraindicated (CKD/PUD/CVD) (Weak analgesic adjunct / NSAID-sparing (JOSPT 2022 Lafrance))
6. methylprednisolone (or triamcinolone — rxcui omitted) 40 mg subacromial/intra-articular, single subacromial / intra-articular single; ceiling ≤2–3 per shoulder — Refractory pain limiting rehab; frozen-shoulder freezing phase (Transient benefit only; image guidance not required (Bloom Cochrane 2012 PMID 22895984); frozen shoulder per UK FROST PMID 33010843)

Non-pharmacologic actions:
- Reassurance + de-emphasise structural labels (degenerative tears often asymptomatic in older adults) (JOSPT 2022 Lafrance)
- Activity / work modification + return-to-work plan developed early and collaboratively (JOSPT 2022 Lafrance return-to-work module)
- Return-to-sport planning for overhead athletes (JOSPT 2022 Lafrance)
- Frozen shoulder: early structured physiotherapy + home stretching through all phases (UK FROST Rangan 2020)
- Expedited orthopaedic referral for acute traumatic full-thickness tear in an active patient (the time-critical exception) (Cochrane 2019 PMID 31813166)

AVOID / contraindication checks:
- NSAID block if eGFR<30 or active PUD or severe CVD (calc.ckd_epi_2021 race neutral CKD EPI 2021 gate) (JOSPT 2022 Lafrance)
- Corticosteroid injection counsel transient hyperglycaemia in diabetes (Zreik PMID 27331029; JOSPT 2022 Lafrance)
- Enforce corticosteroid injection ceiling per shoulder (Bloom Cochrane 2012 PMID 22895984)
- Do not default to subacromial decompression for tendinopathy (CSAW Beard Lancet 2018 PMID 29169668; JOSPT 2022 Lafrance)
- Acetaminophen 2 3g cap if Child Pugh B C (JOSPT 2022 Lafrance)
- Avoid NSAID in pregnancy from 20 weeks and 3rd trimester (JOSPT 2022 Lafrance)
- STOPP START deprescribe chronic NSAID in elderly with CKD HF PUD anticoagulation (STOPP/START v3)
- Do not apply adult cuff degeneration model under 18y (population guardrail)
- Deprescribe:stop NSAID once exercise tolerated or comorbidity flag (JOSPT 2022 Lafrance — pharm adjunct only)

Monitoring

Regimen monitoring:
- pain and function reassessment q6-12wk (JOSPT 2022 Lafrance)
- NSAID renal GI CVD safety review each visit (calc.ckd epi 2021 race-neutral) (JOSPT 2022 Lafrance)
- corticosteroid injection count tracked against ceiling (Bloom Cochrane 2012 PMID 22895984)
- glucose monitoring after steroid in diabetes (Zreik PMID 27331029)
- STOPP START NSAID deprescribing review in elderly (STOPP/START v3)
- re-phenotype or image if no progress after adequate trial; recompute conditioned post-test probability (JOSPT 2022 Lafrance)

Setting (outpatient) monitoring:
- Pain + function + ROM reassessed q6–12 wk; expect slow recovery (JOSPT 2022 Lafrance)
- NSAID renal/GI/CVD safety review each visit (calc.ckd_epi_2021) (JOSPT 2022 Lafrance)
- Corticosteroid-injection count vs ceiling; glucose after steroid in diabetes (Bloom Cochrane 2012; Zreik)
- Re-phenotype / consider delayed imaging if no progress after an adequate trial (JOSPT 2022 Lafrance)

Follow-up plan: Exercise maintenance, activity / work modification, return-to-work and return-to-sport planning (JOSPT 2022 Lafrance return-to-work module), recurrence and red-flag return precautions; re-evaluate persistent / worsening symptoms for re-phenotyping or delayed imaging / surgical opinion (JOSPT 2022 Lafrance)
- Close-out criterion: Long-term self-management + return-to-work/sport + return precautions in place

Monitoring phase: Re-screen red flags at each visit; reassess pain / function and ROM; expect SLOW recovery (weeks–months for cuff/subacromial; 1–3 y natural history for frozen shoulder); NSAID safety review (renal/GI/CVD); enforce the corticosteroid-injection number ceiling; diabetic glucose monitoring after steroid (JOSPT 2022 Lafrance; UK FROST Rangan 2020)

Disposition

Current setting: outpatient — Phenotype the shoulder, screen the cannot-miss / surgical-window causes, deliver education + progressive exercise as first-line, gate pharm/injection adjuncts by comorbidity, and refer surgically only by criteria/timing (JOSPT 2022 Lafrance; AAOS 2019; UK FROST Rangan 2020)

Disposition criteria:
- Continue outpatient exercise-first management with scheduled review (JOSPT 2022 Lafrance)
- Expedited surgical referral for acute traumatic full-thickness tear / recurrent instability (Cochrane 2019 PMID 31813166; AAOS 2019)
- ED transfer for septic / vascular / acute neuro / unreduced dislocation (JOSPT 2022 Lafrance; AAOS 2019)

Escalation triggers (move to higher acuity):
- Acute trauma + sudden cuff weakness in an active patient → expedited orthopaedic referral (surgical window); co-screen occult fracture → route msk.fracture-triage.core.v1 (Cochrane 2019 PMID 31813166)
- Conditioned full-thickness composite LR+ ≥20 (Gwark & Park 2019 PMID 31699076 LR+ 19.07 + lidocaine-persistent lag-sign cluster Bak 2010 PMID 20511030) → targeted imaging only if it changes management + surgical opinion if functionally significant
- Fever + hot swollen shoulder → ED for urgent joint aspiration (septic arthritis) (JOSPT 2022 Lafrance)
- Night pain + weight loss + smoking / fixed mass → urgent imaging for malignancy / Pancoast (AAOS 2019)
- Severe pain then patchy weakness after viral/immunisation prodrome → neurology (Parsonage-Turner) (AAOS 2019)
- Negative shoulder provocative cluster + Spurling-positive neck → route msk.mechanical-neck-pain.core.v1 (carryover provocative cluster + ROM map) (JOSPT 2022 Lafrance)
- Symmetric inflammatory polyarthritis + raised CRP/ESR → route rheum.rheumatoid-arthritis.core.v1 (carryover joint count + markers) (AAOS 2019)
- Dominant glenohumeral/AC degenerative change on radiograph → route msk.osteoarthritis.core.v1 (carryover grade + ROM map)
- Widespread-pain pattern with normal structural workup → route msk.fibromyalgia.core.v1 (carryover WPI + sleep burden)
- Unreduced dislocation or vascular/neuro compromise → ED now (AAOS 2019)
- Refractory frozen shoulder after 3–6 mo structured physiotherapy + steroid → BESS/BOA escalation (MUA / capsular release) (UK FROST Rangan 2020 PMID 33010843)

Patient Action Plan

**Shoulder pain self-management + exercise plan**
Personalised values: phenotype, exercise_programme, comorbid_CKD_GI_CVD_diabetes, occupational_demand.

**Improving with exercise** (green):
Triggers:
- Pain decreasing and function improving over weeks
- Able to do the exercise programme
- No new weakness, numbness, fever or systemic symptoms
Actions:
- Keep doing the progressive exercise programme — recovery is slow (weeks to months) (JOSPT 2022 Lafrance)
- Modify aggravating activities and work tasks rather than stopping the arm completely
- Use NSAID or paracetamol only short-term for pain that limits your exercises, per your prescriber (JOSPT 2022 Lafrance)
- Continue maintenance exercises even once you feel better to prevent recurrence

**Not improving / persistent pain** (yellow):
Triggers:
- No improvement after several weeks of exercise
- Pain or stiffness limiting daily activities or sleep
- Shoulder getting progressively stiffer in all directions
Actions:
- Continue exercises and contact your provider for review and re-assessment (JOSPT 2022 Lafrance)
- A single steroid injection may be offered for short-term relief — its benefit is temporary (Bloom Cochrane 2012)
- Frozen shoulder follows a long natural course — structured physiotherapy is the mainstay (UK FROST Rangan 2020)
Contact provider when:
- No progress after an adequate exercise trial
- Pain regularly waking you at night
- Stiffness rapidly worsening in all directions

**Cannot-miss / urgent** (red):
Triggers:
- Sudden severe weakness after an injury (possible acute tear needing prompt surgery) (Cochrane 2019)
- Fever with a hot, swollen, very painful shoulder (possible infection)
- New numbness/weakness in the arm, chest pain, or pain radiating from the neck
- Shoulder stuck out of joint after a dislocation, or cold/pale hand
Actions:
- Seek urgent medical care / go to the emergency department now
- For sudden weakness after trauma, ask specifically about a torn rotator cuff and timely surgical review (Cochrane 2019 PMID 31813166)
- Bring your medication and medical history (diabetes, kidney disease, blood thinners)
Contact provider when:
- Always seek emergency care for fever + hot joint, sudden post-injury weakness, vascular/neuro signs, or an unreduced dislocation (JOSPT 2022 Lafrance; AAOS 2019)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Fever / systemic illness with a hot, swollen, exquisitely painful shoulder and global motion loss (JOSPT 2022 Lafrance)
- [SEVERE] Acute trauma (fall on outstretched arm / forced abduction) followed by sudden cuff weakness in a younger active patient — time-critical surgical window (JOSPT 2022 Lafrance; Cochrane 2019 PMID 31813166)
- [SEVERE] Full-thickness-tear composite reaching a STRONG rule-IN LR+: the Gwark & Park 2019 multivariable model (age ≥67 + subscapularis tear + Patte retraction ≥2 + hs-CRP >1 mg/L + pain VAS ≥7) gives LR+ 19.07 / post-test 96% (PMID 31699076); chained with a lag-sign cluster that PERSISTS after a subacromial-lidocaine block (specificity/LR rises post-block — Bak 2010 PMID 20511030 Level-I) in the trauma/age-conditioned prior, the wired composite LR+ exceeds 20. The cluster LR is computed with conditional dependence, NOT as the product of the singles (Park 2005 PMID 15995110: painful-arc+drop-arm+infraspinatus → post-test 91% for a full-thickness tear from a defined cohort prior)

Citations

- JOSPT Rotator Cuff Disorders Clinical Practice Guideline 2022 (Lafrance) + AAOS Rotator Cuff CPG 2019 + ASES + BESS/BOA Frozen Shoulder Pathway + NICE CKS Shoulder Pain (2024) [PMID:35881707](https://pubmed.ncbi.nlm.nih.gov/35881707/)
- Cited evidence (PMID 17720798) [PMID:17720798](https://pubmed.ncbi.nlm.nih.gov/17720798/)
- Cited evidence (PMID 18996735) [PMID:18996735](https://pubmed.ncbi.nlm.nih.gov/18996735/)
- Cited evidence (PMID 28122541) [PMID:28122541](https://pubmed.ncbi.nlm.nih.gov/28122541/)
- Cited evidence (PMID 37051997) [PMID:37051997](https://pubmed.ncbi.nlm.nih.gov/37051997/)

Last reconciled with current guidelines: 2026-05-22.
References
  • JOSPT Rotator Cuff Disorders Clinical Practice Guideline 2022 (Lafrance) + AAOS Rotator Cuff CPG 2019 + ASES + BESS/BOA Frozen Shoulder Pathway + NICE CKS Shoulder Pain (2024) — PMID:35881707
  • Cited evidence (PMID 17720798) — PMID:17720798
  • Cited evidence (PMID 18996735) — PMID:18996735
  • Cited evidence (PMID 28122541) — PMID:28122541
  • Cited evidence (PMID 37051997) — PMID:37051997