Troubles des tissus mous de l'épaule

• Use culturally safe, trauma- and violence-informed care. Explain why questions matter, seek permission before sensitive topics, and adapt communication to the patient’s language, identity, culture, disability and previous health care experiences (Public Health Agency of Canada, 2018).
• Ask rather than assume how cultural, family, community, First Nations, Inuit, Métis or other healing practices can be included.
• Patient and contextual information: age; sex and gender when clinically relevant; language and communication needs; occupation or school; caregiving; hand dominance when relevant; sport and recreation; and activities, roles and cultural or community practices important to the patient.

Primary concerns

• Context and onset: gradual or sudden onset; recent or remote trauma; mechanism when relevant; prior episodes; previous shoulder, neck or arm injury; dislocation, subluxation or surgery; training or workload change; and whether symptoms are improving, stable, fluctuating or worsening.
• Location and pattern: duration, course, severity, irritability and 24-hour pattern of shoulder or arm symptoms; sudden loss of strength or movement; clicking, catching, instability, numbness, tingling, swelling, colour or temperature change.
• Aggravating and relieving factors: movement, position, load and time-related behaviour; night symptoms; reaching, lifting, carrying, pushing, pulling, overhead activity, dressing, grooming, driving and lying on the affected side; and response to rest, movement, position or load change.
• Associated symptoms and participation: neck, chest, arm, neurological or systemic symptoms and effects on sleep, self-care, work, school, caregiving, recreation, sport, relationships and other valued activities.
• Revue des systèmes corporels : constitutional and infectious; neurological; cardiovascular and peripheral vascular; respiratory; gastrointestinal and genitourinary; inflammatory or immune; musculoskeletal and bone health; endocrine or metabolic; skin; haematologic; sleep; cognition; and mood symptoms that may change safety, the differential diagnosis, care or referral.
• Health, lifestyle and history: past health conditions and musculoskeletal concerns; diabetes, thyroid disease, inflammatory disease, cancer and bone health; injuries, hospitalizations and surgery; medicines and supplements, including anticoagulants and corticosteroids when relevant; physical activity, training, sleep, smoking, alcohol and substance use; and family history relevant to inflammatory, neurological, cardiovascular or musculoskeletal health.
• Social determinants of health: work, education, caregiving, income, housing, food security, discrimination, safety, social support and access to appropriate care when these may shape health, care or participation (Public Health Agency of Canada, 2026a).
• Soins et interventions antérieurs : advice, rehabilitation, medication, injection, investigations, surgery or self-management tried; what helped or did not help; adverse effects; and reasons care was difficult to use or continue.
• Patient perspective: understanding of the problem, priorities, preferences, cultural context, concerns, expectations, confidence, strengths and previous experiences of care.
• Flag review: check Red Flags and refer to the separate fixed Orange Flags and Yellow Flags modules when relevant.

Outcome measures

• Use a small set that matters to the patient and is practical to repeat. Record a baseline and reassess often enough to guide decisions.
• Patient-specific functioning: Patient-Specific Functional Scale (PSFS).
• Disability and participation: WHO Disability Assessment Schedule 2.0 (WHODAS 2.0).
• Qualité de vie : WHOQOL-BREF when it fits the clinical question.
• Shoulder and upper-limb symptoms and functioning: the Shoulder Pain and Disability Index (SPADI) ou QuickDASH when a condition-specific measure will inform care.
• Symptoms and performance: a pain rating and a small number of repeatable findings or tasks relevant to the person’s goals, such as sleep, reaching, dressing, lifting, carrying, pushing, pulling, overhead work or sport, when safe.
• Objectifs individuels : agree on patient-defined goals and how progress will be recognized. SMART wording may be used when helpful.

Orange Flags are signs that a mental health or substance use concern may require emergency or timely assessment or shared care, and may change whether and how MSK care proceeds. They are not diagnoses. Ask directly and respectfully when concern arises, considering immediate safety, severity, change from usual, daily functioning and context. Psychosocial factors that may affect recovery but do not require separate mental health or medical assessment are addressed under Yellow Flags.

ACTION: Arrange emergency assessment now when there is immediate danger or an urgent medical need:

• Suicide, self-harm or harm to others: current intent or plan, a recent attempt, inability to stay safe, or behaviour suggesting an immediate risk of serious harm.
• Severe change in mental state: extreme agitation, confusion, disorganization, possible psychosis or mania with impaired judgment or unsafe behaviour, or inability to meet basic needs when this creates immediate danger.
• Substance-related or medical emergency: suspected overdose, severe intoxication, dangerous withdrawal, delirium or another sudden change requiring urgent medical care.

When immediate safety is uncertain, do not leave the person alone while help is arranged. Follow local emergency procedures and call 9-1-1 for immediate danger or urgent medical need. If the person is thinking about suicide, call or text 9-8-8: Suicide Crisis Helpline with them or support them to do so.

If violence, abuse or exploitation is disclosed or suspected, support immediate safety and follow applicable safety and reporting requirements.

ACTION: Arrange prompt medical or mental health assessment when there is:

• Suicide or self-harm thoughts: thoughts without immediate danger.
• Substantial symptoms or effects: severe, persistent or worsening symptoms of depression, anxiety, trauma, possible psychosis or mania, eating problems or substance use that substantially affect daily life, decision-making or safe participation in care.
• Other reasons for assessment: a marked change from usual behaviour or functioning; concern about medication or substance effects; a presentation outside the clinician’s competence; or a request for help.

Agree with the patient on who will be contacted, how soon and what to do if the situation worsens. Confirm that the person has connected with the service when clinically important.

ACTION: Adapt and coordinate MSK care:

• Safe care: care may continue when it is safe and acceptable and does not delay needed assessment. Adapt communication, examination and care; obtain ongoing consent; and coordinate with other providers with the patient’s permission.
• Continue the MSK assessment: do not assume that a mental health or substance use concern explains the MSK presentation. Continue to consider physical causes and the patient’s account.
• Questionnaires: they may support conversation and monitoring, but do not establish a diagnosis or replace direct questions, clinical judgment or action.
• Acceptable support: ask what type of help is acceptable and whether language, cultural, family, community or other supports are important to the patient.

ACTION: Document and follow up:

Record the concern; relevant questions and the patient’s responses; the safety decision and reasons; actions, advice and referrals; communication and consent; follow-up; and any unresolved concern. Follow applicable privacy, safety and reporting requirements.

For provincial, territorial and national services, see Mental health support: Get help (Public Health Agency of Canada 2026).

Yellow Flags are personal, social, work, school, healthcare, environmental or structural factors that may influence symptoms, functioning, participation or response to care. They are contextual, not diagnoses or certain predictions, and do not mean that symptoms are psychological. They guide how care is tailored and do not by themselves require urgent referral. Explore them through conversation and ongoing outcome review, with attention to the patient’s priorities, strengths and circumstances. A separate Yellow Flag score is not required. New or worsening signs of serious physical illness follow the Red Flag process. Mental health or substance use concerns that need separate assessment, or any immediate safety concern, follow the Orange Flag process and applicable emergency or safeguarding procedures.

Explore relevant factors:

• Understanding, expectations and healthcare experiences: concerns about injury or damage, uncertainty, recovery expectations, confidence, conflicting advice, previous dismissal or harm, and trust in care.
• Responses to symptoms and activity: worry, fear, avoidance, cycles of doing too much and then needing prolonged rest, difficulty pacing, coping, sleep, confidence in self-management, and return to meaningful activities.
• Emotional and life context: distress, low mood, anxiety, grief, trauma, caregiving, relationship change, job loss or other major events. Ask permission before sensitive questions and limit discussion to what is relevant and acceptable to the patient.
• Relationships, culture and strengths: supportive relationships, isolation, family and community roles, cultural or spiritual practices, identity, preferences, language and other sources of resilience.
• Work, school and administrative context: physical and psychosocial demands, control, satisfaction, job security, accommodations, return concerns, and compensation, insurance or legal processes. Explore these neutrally and in context.
• Social and structural conditions: consider social and structural determinants of health (Public Health Agency of Canada 2026), including income, housing, food security, transportation, childcare, access and cost of care, discrimination, racism, colonialism, neighbourhood and workplace conditions, and physical or digital accessibility.

ACTION: Respond with the patient:

• Ask, do not assume: use open questions to understand what helps, what gets in the way, what matters and what feels feasible. Ask about strengths and protective factors, not only difficulties. Do not treat a person’s circumstances, culture or choices as a deficit.
• Plan together: integrate relevant findings into shared goals, education, self-management, physical activity or exercise, and participation in meaningful activities. Adapt communication, setting, pace, cost and access where possible.
• Connect and coordinate: with the patient’s consent, consider appropriate clinical, social, workplace, school, community, Indigenous or culturally specific supports. Clarify who will do what and follow up when the connection is important to the plan.
• Review response to care: reassess the patient’s account and the pathway’s selected outcomes at clinically relevant points. If progress differs from expected, review the clinical impression, care plan, access and other barriers; do not automatically attribute the outcome to Yellow Flags.
• Document: record relevant factors and strengths, the patient’s priorities and preferences, agreed actions, consent, referrals or coordination, follow-up, and any change requiring the Orange Flag process.

Select examination elements that answer a clinical question or may change care. Adapt the examination to the patient’s presentation, comfort, consent and abilities.

• Consent and comfort: explain what you propose, provide choices about positioning, draping, pace and support, and confirm ongoing consent before provocative, neurological or hands-on testing.
• Condition-specific safety: defer or modify examination when suspected fracture, dislocation, infection, acute neurovascular compromise, severe irritability or another safety concern makes testing inappropriate.
• Observation and relevant vital signs: general appearance, distress, swelling, deformity, skin change, muscle wasting, protective behaviour, scapular movement and use of the arm; assess vital signs when systemic, cardiovascular or another non-musculoskeletal concern makes them relevant.
• Movement and range of motion: compare active and passive shoulder movement, especially elevation and external rotation, noting range, quality, symptom response and whether restriction is global or direction-specific. A goniometer or inclinometer can improve repeatability when objective measurement will guide care (Desmeules et al., 2025).
• Strength and load tolerance: assess relevant shoulder strength and symptom response when safe. A handheld dynamometer can improve repeatability when objective measurement will guide care. Sudden marked weakness after trauma changes referral urgency (Desmeules et al., 2025).
• Neurological and neurovascular examination when indicated: motor performance, sensation, reflexes, upper motor neuron findings and neurovascular status when numbness, weakness, neck symptoms, gait change or safety concerns are present.
• Special or orthopaedic tests: use a small set within a combined assessment of the working presentation. No single test establishes a definitive tissue source (Desmeules et al., 2025; Lowry et al., 2024).
• Palpation : focal tenderness, swelling, temperature or symptom reproduction when this contributes to the assessment; palpation alone does not establish a specific pain source.
• Évaluation fonctionnelle : select safe tasks relevant to the patient’s goals, such as reaching, dressing, lifting, carrying, pushing, pulling, overhead work, sport or caregiving activities.
• Imagerie : not routine for an initial atraumatic rotator cuff-related presentation. Radiographs are relevant after important trauma or when fracture, dislocation, arthritis, calcification or another bony condition is suspected. Ultrasound, magnetic resonance imaging or other imaging can be used when the result is likely to change care or referral (American College of Radiology, 2024; American College of Radiology, 2023; Desmeules et al., 2025).
• Repeat and adapt: review the findings and tasks needed to assess progress, revisit the working clinical presentation or decide whether further assessment or referral is appropriate.

Working clinical presentations

Use these as working clinical descriptions rather than definitive tissue diagnoses. Presentations can overlap or change, and structural findings may not explain the person’s symptoms or functioning (Desmeules et al., 2025; Lowry et al., 2024; Rees et al., 2021).

• Rotator cuff-related shoulder pain: pain commonly occurs with elevation, reaching, lifting, resisted shoulder loading or lying on the affected side. Active movement or strength may be more affected than passive movement. This presentation can include rotator cuff tendinopathy, partial-thickness tear, subacromial pain or related bursal symptoms; the term impingement does not establish a mechanism (Desmeules et al., 2025; Rees et al., 2021).
• Shoulder stiffness or adhesive capsulitis: pain and progressive stiffness with marked restriction of active and passive movement, often including external rotation. Diabetes, thyroid disease and bony or other causes may change assessment or care (Rees et al., 2021).
• Calcific rotator cuff tendinopathy: a calcific presentation can resemble other rotator cuff-related pain or cause a sudden severe episode. Imaging confirms calcification when the result will change care (Desmeules et al., 2025; Rees et al., 2021).
• Instability: apprehension, a sense of slipping, recurrent subluxation or dislocation, or symptoms in positions of vulnerability. Distinguish traumatic from atraumatic onset and record recurrence, activity demands and voluntary or involuntary episodes (Rees et al., 2021).
• Acromioclavicular, biceps-related or labral presentation: localized superior pain with cross-body or load-bearing tasks may suggest acromioclavicular involvement. Anterior pain, clicking or catching may involve the long head of biceps tendon or labrum, but individual tests have limited ability to identify one structure (Lowry et al., 2024).
• Alternative or overlapping presentation: global passive restriction with crepitus may suggest glenohumeral osteoarthritis. Neck or nerve-root conditions, peripheral neuropathy, inflammatory disease and cardiovascular, pulmonary, gastrointestinal or other referred sources can overlap with shoulder symptoms. Refer or coordinate care when needs extend beyond the clinician’s role (Rees et al., 2021).

Develop care with the patient. Choices reflect the working presentation, safety, goals, preferences, culture, access, other health conditions, previous responses and treatment burden. Respect the patient’s right to accept, decline, limit or stop any part of care.

Education, self-management and participation

• Condition and self-management information: options include a clear explanation of the working presentation, activity and pain-management strategies, pacing and gradual resumption of daily, work and sport activities (Desmeules et al., 2025; Yu et al., 2021).
• Participation planning: build return to work, school, caregiving, recreation or sport around current capacity, repeated outcomes, confidence and task demands rather than a fixed calendar.

Protection and optimal loading

• Acute injury: options include brief relative protection, temporary support and reduction of the provoking load when needed for comfort and safe daily activity, followed by progressive movement and loading as the presentation permits. Suspected fracture, dislocation or acute traumatic tear follows Red Flags (Desmeules et al., 2025; Rees et al., 2021).
• Persistent load-related pain: temporary changes to reaching, lifting, carrying, pushing, pulling, overhead work, side-lying or training load can reduce repeated provocation while maintaining feasible movement and participation. Reintroduce tasks as capacity and confidence improve (Desmeules et al., 2025; Yu et al., 2021).
• Presentation-specific loading: stiffness care can emphasize tolerable movement; instability care can build control and capacity around vulnerable positions; and rotator cuff-related care can progress resistance and task load. The choice reflects irritability, safety, goals and response.

Physical activity and exercise

• Progressive exercise: options include individualized mobility, motor-control, resistance, endurance and task-specific exercise. Type, amount and progression reflect the presentation, goals, starting capacity and response (Desmeules et al., 2025; Yu et al., 2021).
• Working-presentation focus: exercise for stiffness, instability and rotator cuff-related pain can emphasize the mobility, control, confidence and loading demands relevant to that presentation without implying one universally correct movement pattern (Desmeules et al., 2025; Rees et al., 2021).
• Return to valued activity: task practice can progress from daily and work demands to higher-load or sport-specific reaching, lifting, carrying, throwing or contact tasks when relevant.

Hands-on and symptom-relieving care

• Shoulder manual therapy: joint mobilization or manipulation and soft-tissue techniques can accompany active care when a short-term change in pain or movement helps participation (Desmeules et al., 2025; Yu et al., 2021).
• Cervicothoracic or thoracic care: mobilization or manipulation is an option when shoulder pain occurs with relevant pain or restricted movement in the cervicothoracic or thoracic region (Yu et al., 2021).
• Other symptom-relieving options: heat or cold, low-level laser therapy and acupuncture can be used when safe, acceptable and linked to a specific symptom or participation goal. Review whether the option adds useful benefit (Desmeules et al., 2025; Yu et al., 2021).
• Culturally grounded and personal strategies: traditional, Indigenous, spiritual, community-based or other symptom-relieving approaches identified by the patient can be integrated when safe, acceptable and within scope.

Psychological, social and interdisciplinary support

• Psychologically informed care: supportive communication, graded exposure and coping strategies can form part of care when fear, distress, low confidence, mood or anxiety affects activity or recovery. Coordinate mental-health care when needs extend beyond the clinician’s competence or scope (Desmeules et al., 2025).
• Social and practical support: workplace, school or sport accommodations, community services and culturally specific supports can help participation when they match the patient’s priorities.

Medication and procedural shared care

• Medication questions: short-term acetaminophen or nonsteroidal anti-inflammatory drugs are medical options for rotator cuff tendinopathy. Review current use, expected benefit, contraindications, adverse effects and interactions with an authorized prescriber or pharmacist; prescribing and dosing remain with that provider (Desmeules et al., 2025).
• Corticosteroid injection: can provide short-term pain and disability relief for selected adults with rotator cuff tendinopathy. The medical decision reflects the working diagnosis, expected benefit, risks, previous care and the person’s goals, and does not replace active care (Desmeules et al., 2025).
• Imaging-confirmed calcific rotator cuff tendinopathy: extracorporeal shock-wave therapy, low-level laser therapy or medical assessment for calcific lavage can form part of presentation-specific shared care (Desmeules et al., 2025; Yu et al., 2021).
• Specialist opinion: can form part of shared care for recurrent instability, suspected full-thickness tear, substantial persistent stiffness, severe calcific presentation, uncertain diagnosis or symptoms that remain limiting when further imaging, medical treatment or procedural care may change management.

Monitoring and reassessment

• Agree on a reassessment point based on the presentation, safety, goals, care being tried, patient needs and access rather than a fixed visit schedule.
• Repeat the small outcome set recorded at baseline and review symptoms, relevant neurological findings, movement and load tolerance, functioning, participation, confidence, benefits, adverse effects, treatment burden and progress toward patient-defined goals.
• Continue what is useful and acceptable; adapt or stop what is not; and revisit Red Flags, the working presentation, differential diagnosis, imaging, referral or shared care when progress differs from expectations or new safety concerns emerge.

• Expected course: the course varies by presentation. Rotator cuff tendinopathy often improves with non-surgical care, but symptoms can persist or recur; adhesive capsulitis, recurrent instability and substantial tears follow different courses. Use observed change rather than a fixed timeline (Desmeules et al., 2025; Rees et al., 2021).
• Factors associated with a less favourable course: for rotator cuff tendinopathy and general shoulder pain, longer symptom duration, greater pain, previous shoulder injury, older age, psychological distress, limited social support and high physical or psychosocial work demands may be associated with poorer outcomes. Associations are often weak or based on limited evidence and do not determine an individual’s outcome (Desmeules et al., 2025).
• Potential supports for recovery: feasible self-management and active rehabilitation, confidence, supportive relationships and workplaces, relevant accommodations and access to coordinated care may support recovery (Desmeules et al., 2025; Yu et al., 2021).
• Discussing prognosis: describe uncertainty in plain language, ask what the patient wants to know, and update the outlook using repeated outcomes and the observed course. Do not treat a prognostic factor, imaging finding or screening score as a fixed prediction.