THE PAINFUL SHOULDER - CAN CONSULTANTS AGREE

As a two-phase exercise in inter-district audit, with the emphasis on critical evaluation of routine clinical practice, three rheumatologist s each examined the same 44 patients with shoulder pain, and recorded their diagnosis and the investigations and treatment they would carry out. In the first phase, 26 patients were seen by each rheumatologist separately; there was complete diagnostic agreement in only 46%, with wide variation in the frequency of requests for standard investigation s, but all three rheumatologists recommended steroid injections for mo st patients. In the second phase, all three rheumatologists examined a further 18 patients together, discussed the symptoms and signs, and r ecorded their diagnoses separately. There was complete agreement in 78 %. The presence of more than one lesion, and differences in the interp retation of certain physical signs, partly explain the lack of agreeme nt in Phase 1. Treatment of specific shoulder lesions is highly concor dant, with injection the major treatment modality, followed by physiot herapy. Perhaps the different diagnoses reached, and the fact that tre atment might therefore be administered for the wrong diagnosis, may ex plain some treatment failures. Also, recruitment of patients for studi es of the treatment of shoulder lesions requires care to avoid selecti on of a heterogeneous group.