Transforming shoulder care

Imagine not being able to work or run your business, or that you are a grandparent who cannot push their grandchild on a swing.

Imagine not being able to sleep through the night, or that you are a paramedic who cannot lift a stretcher.

Every year, over 30,000 people in the Central East Local Health Integration Network (Central East LHIN) visit their primary care provider (PCP) because of shoulder pain.

Shoulder pain is second only to low back pain in terms of disability and costs. Patients often experience 12 to 18 months of unresolved pain and discomfort before being referred on to an orthopaedic surgeon. During this time, many patients remain without a concise diagnosis, while receiving unnecessary diagnostic tests, ineffective medication and physiotherapy, only to return to their PCP several times before being referred on to a specialist.

Remarkably, only one in twenty-five shoulder complaints result in surgery. The majority of issues can be solved through non-surgical interventions that do not automatically require a surgeon’s attention.

In Ontario, lengthy wait times to see an orthopaedic surgeon persist in many LHINs, and thus it is not surprising that about 40 per cent of the shoulder patients in the Central East LHIN receive their outside of their region.

With this in mind, has developed a novel specialty care program.

Designed and led by Rouge Valley’s own shoulder surgeons, The Shoulder Centre is transforming the way shoulder pain is treated: redefining and shortening the patient journey, increasing the ease and access to consistent and quality care, as well as addressing system inefficiencies that challenge health service sustainability.

“For primary care providers, determining the next course of action for a patient who comes to them with shoulder pain can be difficult and frustrating,” said Dr. Stephen Gallay, Division Head of Orthopaedics at the Rouge Valley Ajax and Pickering hospital campus and one of the founders of The Shoulder Centre.  “They often order diagnostic tests (including costly MRIs) and try multiple treatments, all in the effort to return the patient to a pain-free state.  The patient is then referred to a shoulder surgeon – sometimes three to twelve months after their first appointment with their PCP – and often without having received a concise diagnosis.”

In contrast, The Shoulder Centre’s new model of care immediately connects the PCP and their patient with the right shoulder specialist.

To do this, the Centre developed a new intelligent e-referral tool to guide the PCP through a more succinct assessment of their patient’s shoulder pain at the time of the patient encounter.

The referral tool generates a report that is triaged to establish which member of the Centre’s multidisciplinary shoulder specialist team will take charge of the patient’s care.  Only then are evidence-based diagnostics used (if needed) to determine the appropriate and most effective treatments, which could mean anything from a cortisone injection performed by a physician assistant or sports medicine physician, to a customized exercise program crafted by a physiotherapist, to surgery booked with an orthopaedic surgeon. Relying on a team rather than on an individual to provide care means the patient is seen sooner. And that means the patient will be pain-free faster.

Just in its first three months, The Shoulder Centre’s team has shortened patients’ wait times to between two to three weeks, and demonstrated significant cost savings to the health-care system.

“We’re really excited that we’ve been able to add a physician assistant [PA] to our team.  We’ve trained her to provide exemplary shoulder care to many of our non-surgical shoulder patients so they don’t have to wait to see one of the surgeons. From a system perspective, the PA is delivering the same quality of care for a particular problem within her scope of practice at a fraction (approximately 25 per cent) of the usual cost that would be charged to OHIP if one of the surgeons treated the patient,” continued Gallay.  “We’ve also projected that with patients being referred directly to The Shoulder Centre, we can reduce the number of MRI tests by two-thirds… that also leads to significant system savings especially when an MRI is priced at $500-$800 a test.”

The next step for the Centre is to empower and educate local PCPs and other allied health providers with shoulder knowledge.  Thus the Centre will no longer be just a physical space that patients must travel to, but rather the hub of a specialty care community comprising of information and expertise that can be found throughout the network. Patients can then stay close to home, but still be confident that they are receiving consistent and quality shoulder care.

“The goal of this model of care is for the patient to easily and quickly reach the right care at the right time, and to also make it efficient and sustainable. We’re starting with transforming shoulder care, but recognize that this model is transferable to other areas in health care,” concluded Gallay.

For more information about The Shoulder Centre located at Rouge Valley Health System as well as to download the referral form, visit