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BMJ Clin Evid. 2006; 2006: 1107.
Published online 2006 September 1.
PMCID: PMC2907630

Shoulder pain

Dr Cathy Speed, BMedSci, FRCP, Dip Sports Med, PhD, Rheumatologist/Director of Sports and Exercise Medicine Unit

Abstract

Introduction

Shoulder pain covers a wide range of problems and affects up to 20% of the population. It is not a specific diagnosis. Shoulder pain can be caused by problems with the acromioclavicular joint, shoulder muscles, or referred pain from the neck. Rotator cuff problems account for 65-70% of cases of shoulder pain.

Methods and outcomes

We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of oral drug treatment; topical drug treatment; local injections; non-drug treatment; and surgical treatment? We searched: Medline, Embase, The Cochrane Library and other important databases up to February 2006 (BMJ Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

Results

We found 53 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

Conclusions

In this systematic review we present information relating to the effectiveness and safety of the following interventions: arthroscopic laser subacromial decompression, corticosteroid injections (intra-articular), corticosteroids (oral, subacromial injection), electrical stimulation, extracorporeal shock wave therapy, guanethidine (intra-articular), ice, laser treatment, manipulation under anaesthesia (plus intra-articular injection in people with frozen shoulder), multidisciplinary biopsychosocial rehabilitation, nerve block, non-steroidal anti-inflammatory drugs (oral, topical or intra-articular injection), opioid analgesics, paracetamol, phonophoresis, physiotherapy (manual treatment, exercises), surgical arthroscopic decompression, transdermal glyceryl trinitrate, ultrasound.

Key Points

Shoulder pain covers a wide range of problems and affects up to 20% of the population. It is not a specific diagnosis.

  • Shoulder pain can be caused by problems with the acromioclavicular joint, shoulder muscles, or referred pain from the neck.

Rotator cuff problems account for 65-70% of cases of shoulder pain.

  • Rotator cuff disorders are associated with musculoskeletal problems that affect the joints and muscles of the shoulder, cuff degeneration due to ageing and ischaemia, and overloading of the shoulder.

Adhesive capsulitis (frozen shoulder) accounts for 2% of cases of shoulder pain.

  • Risk factors for frozen shoulder include female sex, older age, shoulder trauma and surgery, diabetes, and cardiovascular, cerebrovascular and thyroid disease.

In many people, the cornerstone of treatment is achieving pain control to allow appropriate physiotherapy to proceed. In people with acute post traumatic tear, an early surgical option is warranted.

We don't know whether oral or topical NSAIDs, oral paracetamol, opioid analgesics or transdermal glyceryl trinitrate improve shoulder pain. If pain control fails, the diagnosis should be reviewed and other interventions considered.

Physiotherapy improves pain and function in people with mixed shoulder disorders compared with placebo or sham laser treatment.

Intra-articular injections may be beneficial but only if accurately sited.

  • Intra-articular corticosteroid injections may reduce pain in the short term compared with physiotherapy, but their benefit compared with placebo or local anaesthetic is unclear.
  • Clinical outcome correlates with accuracy of injection, but even experienced clinicians may fail to locate the correct site in the majority of cases.

Suprascapular nerve blocks improve pain at 1 month in people with adhesive capsulitis and degenerative disease but we don't know whether it improves shoulder pain from other causes.

Extracorporeal shock wave therapy may improve pain in calcific tendonitis, and manipulation under anaesthesia may reduce symptoms of adhesive capsulitis, but neither intervention is beneficial in rotator cuff lesions.

About this condition

Definition

Shoulder pain arises in or around the shoulder from its joints and surrounding soft tissues. Joints include the glenohumeral, acromioclavicular, sternoclavicular, "subacromial", and scapulothoracic. Regardless of the disorder, pain is the most common reason for consulting a practitioner. In adhesive capsulitis (frozen shoulder), pain is associated with pronounced restriction of movement. Rotator cuff disorders may affect one or more portions of the rotator cuff and can be further defined as rotator cuff tear (partial/full thickness), non-calcific tendinosis (previously termed tendinitis), or calcific tendinitis. A subacromial/subdeltoid bursitis may be associated with any of these disorders, or may occur in isolation. For most shoulder disorders, diagnosis is based on clinical features, with imaging studies playing a role in some people. Post-stroke shoulder pain and pain referred from the cervical spine are not addressed in this chapter.

Incidence/ Prevalence

Each year in primary care in the UK, about 1% of adults aged over 45 years present with a new episode of shoulder pain. Prevalence is uncertain, with estimates from 4-20%. One community survey (392 people) in the UK found a 1 month prevalence of shoulder pain of 34%. A second survey (644 people aged ≥ 70 years) in a community based rheumatology clinic in the UK reported a point prevalence of 21%, with a higher frequency in women than men (25% v 17%). Seventy per cent of cases involved the rotator cuff. Further analysis of 134 people included in the survey found that 65% of cases were rotator cuff lesions; 11% were caused by localised tenderness in the pericapsular musculature; 10% involved acromioclavicular joint pain; 3% involved glenohumeral joint arthritis; and 5% were referred pain from the neck. Another survey in Sweden found that, in adults, the annual incidence of frozen shoulder was about 2%, with those aged 40-70 years most commonly affected. The age distribution of specific shoulder disorders in the community is unknown.

Aetiology/ Risk factors

Rotator cuff disorders are associated with excessive overloading, instability of the glenohumeral and acromioclavicular joints, muscle imbalance, adverse anatomical features (narrow coracoacromial arch and a hooked acromion), cuff degeneration with ageing, ischaemia, and musculoskeletal diseases that result in wasting of the cuff muscles. Risk factors for adhesive capsulitis (frozen shoulder) include female sex, older age, shoulder trauma, surgery, diabetes, cardiorespiratory disorders, cerebrovascular events, thyroid disease, and hemiplegia. Arthritis of the glenohumeral joint can occur in numerous forms, including primary and secondary osteoarthritis, rheumatoid arthritis, and crystal arthritides. Shoulder pain can also be referred from other sites, in particular the cervical spine. It can also arise after stroke. Post-stroke shoulder pain and referred pain are not addressed in this chapter.

Prognosis

One survey in an elderly community found that most people with shoulder pain were still affected 3 years after the initial survey. One prospective cohort study of 122 adults in primary care found that 25% of people with shoulder pain reported previous episodes and 49% reported full recovery at 18 months' follow up.

Aims of intervention

To reduce pain and to improve range of movement and function, with minimal adverse effects.

Outcomes

Pain scores (overall score, on activity, at night, at rest, during the day, analgesia count); range of movement measures; assessment of overall severity (self assessed or by blinded assessor); functional score; global improvement scores (self assessed or by blinded assessor); tenderness; strength; stiffness; rates of withdrawal from the trial; and adverse effects of treatment. The shoulder pain and disability index is a validated shoulder related pain and disability questionnaire. Other validated participant rated disability scores have been developed.

Methods

Clinical Evidence search and appraisal February 2006. For this chapter various sources were used for the identification of studies - Medline 1966 to February 2006, Embase 1980 to February 2006, The Cochrane Library to Issue 1 2006. Additional searches were carried out on the NHS Centre for Reviews and Dissemination (CRD), Database of Abstracts of Reviews of Effects (DARE), Health Technology Assessment (HTA), Turning Research into Practice (TRIP) & the National Institute of Health and Clinical Excellence guidance (NICE) websites. Abstracts of studies retrieved in the search were assessed independently by 2 information specialists. Pre-determined criteria were used to identify relevant studies. Study design criteria included: systematic reviews, RCTs. At least single blind. We excluded all studies described as ‘open’, ‘open label’ or non-blinded. The minimum number of individuals in each trial was 20. Size of follow up was 80% or more. There was no minimum length of follow up. We have performed a GRADE evaluation of the quality of evidence for interventions included in this review (see table ).

Table
GRADE evaluation of interventions for shoulder pain

Glossary

Interferential electrical stimulation
Typically, a high frequency current (4000 Hz) amplitude modulated at a lower frequency (60–100 Hz) given in bursts of 4 seconds and repeated for up to 15 minutes.
Low-quality evidence
Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Maitland mobilisation
A graded system of manipulations and exercises intended to increase mobility of specific joints.
Moderate-quality evidence
Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Multidisciplinary biopsychosocial rehabilitation
Combined physical, social, and psychological rehabilitation.
Neer score
Assesses pain during the past week, clinical testing of shoulder function, active range of movement, and anatomical or radiological examination. Scores range from 0–100 points.
Phonophoresis
The application of topical medication followed by ultrasound to the same area, the theory being that the ultrasound energy drives the medication through the skin.
Shoulder pain and disability index (SPADI)
A self administered instrument for measuring pain (5 items) and disability (8 items).
Very low-quality evidence
Any estimate of effect is very uncertain.

Notes

Disclaimer

The information contained in this publication is intended for medical professionals. Categories presented in Clinical Evidence indicate a judgement about the strength of the evidence available to our contributors prior to publication and the relevant importance of benefit and harms. We rely on our contributors to confirm the accuracy of the information presented and to adhere to describe accepted practices. Readers should be aware that professionals in the field may have different opinions. Because of this and regular advances in medical research we strongly recommend that readers' independently verify specified treatments and drugs including manufacturers' guidance. Also, the categories do not indicate whether a particular treatment is generally appropriate or whether it is suitable for a particular individual. Ultimately it is the readers' responsibility to make their own professional judgements, so to appropriately advise and treat their patients.To the fullest extent permitted by law, BMJ Publishing Group Limited and its editors are not responsible for any losses, injury or damage caused to any person or property (including under contract, by negligence, products liability or otherwise) whether they be direct or indirect, special, incidental or consequential, resulting from the application of the information in this publication.

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2006; 2006: 1107.
Published online 2006 September 1.

Corticosteroids (oral)

Summary

SYMPTOM SEVERITY Compared with placebo: Oral corticosteroids may not reduce pain at 3–18 weeks in people with adhesive capsulitis compared with placebo ( very low-quality evidence ). Oral corticosteroids plus home exercises compared with home exercises alone: Oral corticosteroids plus advice on home pendular exercises may not reduce pain at 8 months in people with adhesive capsulitis compared with home exercises alone (very low-quality evidence). FUNCTIONAL IMPROVEMENT Compared with placebo: Prednisolone improves disability, range of active motion, and overall participant-rated improvement compared with placebo ( moderate-quality evidence ). NOTE The adverse effects of corticosteroids are well documented.

Benefits

Oral corticosteroids versus placebo:

We found no systematic review but found two RCTs. The first RCT (32 people with adhesive capsulitis [frozen shoulder]) compared oral corticosteroids (cortisone acetate, 200 mg a day for the first 3 days, 100 mg up to day 14, then 12.5 mg every 2 days up to 4 weeks) versus placebo. It found no evidence that oral corticosteroids reduced pain more than placebo after 18 weeks, but intergroup comparisons were not reported (mean improvement on 4 point rating scale [0 = no pain, 3 = severe pain]: from 1.4 at baseline to 0.5 with oral corticosteroids v 1.4 at baseline to 0.6 with placebo; P values not reported). The second RCT (50 people with adhesive capsulitis) compared oral prednisolone (30 mg daily) versus placebo for 3 weeks. It found that oral prednisolone significantly reduced overall pain at 3 weeks compared with the placebo group (mean change from baseline measure on a scale from 0–10, where 0 = no pain: 4.1 with prednisolone v 1.4 with placebo; adjusted difference in means: 2.4, 95% CI 1.1 to 3.8). There was also greater improvement in disability, range of active motion, and participant rated improvement (proportion of participants who reported marked or moderate overall improvement: 22/23 [96%] with prednisolone v 11/23 [48%] with placebo; RR 2.0, 95% CI 1.3 to 3.1). At 6 weeks, the analysis favoured the prednisolone group for most outcomes but none of the differences were significant. At 12 weeks, the analysis tended to favour the placebo group, although, again, for most outcomes the differences between groups were not significant.

Oral corticosteroids plus home exercise versus home exercise alone:

We found one small RCT (40 people with adhesive capsulitis). People in both groups also took non-salicylate analgesics and diazepam (5 mg) at night as needed. The RCT found no significant difference between oral corticosteroids (10 mg for 4 weeks and 5 mg for a further 2 weeks) plus advice on home pendular exercises and advice alone for pain at 8 months (figures not reported).

Harms

The adverse effects of corticosteroids are well documented (see Clinical Evidence chapter on asthma). One RCT (40 people with adhesive capsulitis) reported mild indigestion in two people, which settled after reducing the dose of oral corticosteroids below 10 mg. No other adverse effects were reported. The other RCT gave not information on adverse effects.

Comment

None.

Substantive changes

No new evidence

2006; 2006: 1107.
Published online 2006 September 1.

NSAIDs (oral)

Summary

SYMPTOM SEVERITY Compared with placebo: Oral NSAIDs may reduce pain in people with acute tendonitis and/or subacromial bursitis compared with placebo ( very low-quality evidence ). ADVERSE EFFECTS NSAIDs are associated with adverse ffects such as gastrointestinal symptoms, skin rash, headache, and dizziness.

Benefits

Oral NSAIDs versus placebo:

We found one systematic review (search date 1998, 4 small RCTs, 151 people with shoulder pain for more than 72 hours), one additional, and one subsequent RCT. The review pooled results from RCTs that reported sufficient data (2 RCTs, 90 people with rotator cuff tendinitis) and found no significant reduction in pain and no significant improvement in abduction between the oral NSAIDs (NSAIDs) diclofenac or naproxen and placebo after 4 weeks (pain: visual analogue scale, WMD 3 cm, 95% CI –19 cm to + 25 cm, where positive values represent deterioration; abduction: WMD + 26°, 95% CI –9° to + 61°, where positive values represent improvement). The additional RCT (69 people with acute shoulder pain of less than 96 hours' duration) found that oral flurbiprofen (300 mg/day) significantly improved pain relief, as judged by the investigator, compared with placebo at 14 days (global assessment by investigator: 30/35 [86%] improved with NSAID v 19/32 [59%] with placebo; ARR 26%, CI 5% to 46%; NNT 4, 95% CI 3 to 20). The subsequent RCT (306 people with acute onset shoulder tendinitis and/or subacromial bursitis) compared three interventions: celecoxib (initial dose 400 mg plus 200 mg 8 hours later, followed by 200 mg twice daily), naproxen (500 mg twice daily), or placebo (twice daily) for 14 days. A total of 254 people completed the trial; results were analysed by intention to treat. The RCT found that celecoxib significantly reduced pain at 7 and 14 days compared with placebo (mean reduction from baseline in Maximum Pain Intensity at Rest measured on a visual analogue scale, where 0 mm = no pain and 100 mm = worst pain; at 7 days: –27.7 mm with celecoxib v –18.4 mm with placebo; P < 0.05; at 14 days: –35.0 mm with celecoxib v –25.0 mm with placebo; P < 0.05). It also found that naproxen significantly reduced pain at 7 days compared with placebo (mean reduction from baseline in Maximum Pain Intensity at Rest measured on the same visual analogue scale: –26.4 mm with naproxen v –18.4 mm with placebo; P < 0.05), but found no significant difference in pain at 14 days (reported as non-significant, absolute results not reported). Secondary measures of efficacy, such as Physician′s Global Assessment of Shoulder Tendinitis and/or Bursitis, also found that celecoxib and naproxen were significantly better than placebo.

Harms

The review found insufficient evidence from one RCT to assess the adverse effects of oral NSAIDs compared with placebo. It found no evidence that the incidence or nature of adverse effects varied among NSAIDs (naproxen, diclofenac, flurbiprofen, indometacin, etodolac, ibuprofen, fentiazac, phenylbutazone, piroxicam). Adverse effects were mostly gastrointestinal symptoms, skin rash, headache, or dizziness. The additional RCT found that 8/35 (23%) people taking flurbiprofen had adverse effects compared with 3/34 (9%) taking placebo; almost all adverse effects were gastrointestinal symptoms; the RCT did not assess the significance of the difference between groups. The subsequent RCT found that 36.7% of people taking celecoxib, 36.0% taking naproxen, and 29.6% taking placebo had adverse effects, primarily headache, dyspepsia, and nausea; the RCT did not assess the significance of the difference between groups. We found no systematic review of the adverse effects of cyclo-oxygenase type 2 selective agents in people with shoulder pain (see differences between NSAIDs in the NSAIDs chapter). Withdrawal because of adverse effects occurred in less than 10% of people in non-randomised comparative studies, but in up to 20% of people in RCTs.

Comment

Clinical guide:

Evidence about the effects of NSAIDs in shoulder disorders is limited by the lack of standardised approaches: diverse disorders have been considered under the universal term “shoulder pain”, different types of NSAIDs were used, and outcome measures and follow up periods vary among RCTs. In addition, pain is a symptom, and so relying on investigator rated pain may not be valid.

Substantive changes

No new evidence

2006; 2006: 1107.
Published online 2006 September 1.

Opioid analgesics

Summary

We found no direct information about the effects of opioid analgesics in people with shoulder pain.

Benefits

We found no systematic review or RCTs evaluating opioid analgesics in people with shoulder pain.

Harms

We found no RCTs.

Comment

None.

Substantive changes

No new evidence

2006; 2006: 1107.
Published online 2006 September 1.

Paracetamol

Summary

We found no direct information about the effects of paracetamol in people with shoulder pain.

Benefits

We found no systematic review or RCTs evaluating paracetamol in people with shoulder pain.

Harms

We found no RCTs.

Comment

None.

Substantive changes

No new evidence

2006; 2006: 1107.
Published online 2006 September 1.

NSAIDs (topical)

Summary

We found no direct information about the effects of topical NSAIDs in people with shoulder pain.

Benefits

We found no systematic review or RCTs of topical NSAIDs in people with shoulder pain.

Harms

We found no RCTs.

Comment

See topical NSAIDs in review on NSAIDs.

Substantive changes

No new evidence

2006; 2006: 1107.
Published online 2006 September 1.

Phonophoresis

Summary

SYMPTOM SEVERITY Compared with placebo/sham phonophoresis: Phonophoresis may not reduce pain or tenderness in people with tendinitis compared with placebo or sham phonophoresis ( very low-quality evidence ). NOTE We found no direct information about the effects of phonophoresis solely in people with shoulder pain.

Benefits

We found no systematic review.

Phonophoresis versus placebo or sham phonophoresis:

We found no RCTs solely in people with shoulder pain. We found one RCT (24 people, 13 with rotator cuff tendinitis, 1 with biceps tendinitis, 1 triceps tendinitis, 9 with knee tendinitis) comparing active phonophoresis using topical dexamethasone, lidocaine, and aqueous gel versus placebo phonophoresis using aqueous gel only (5 sessions over 5–10 days). It found no significant difference in perceived pain (visual analogue scale [0 cm = no pain, 10 cm = extreme pain]; pain changed from 2.4 cm to 1.3 cm with active treatment v from 2.6 cm to 1.5 cm with placebo; not significant, P value not reported). It found no significant difference in tenderness between phonophoresis and placebo (localised force needed to elicit pain: 198 g, 95% CI 164 g to 235 g, at session 1 to 204 g, 95% CI 170 g to 238 g, at session 5 with active phonophoresis v 196 g, 95% CI 153 g to 235 g, at session 1 to 249 g, 95% CI 221 g to 275 g, at session 5 with placebo phonophoresis).

Phonophoresis versus other treatment:

We found no RCTs.

Harms

The RCT gave no information on adverse effects.

Comment

None.

Substantive changes

No new evidence

2006; 2006: 1107.
Published online 2006 September 1.

Transdermal glyceryl trinitrate

Summary

SYMPTOM SEVERITY Compared with placebo: Transdermal glyceryl trinitrate may reduce pain or tenderness at 24 hours to 15 days compared with placebo in people with supraspinatus tendinitis ( very low-quality evidence ). FUNCTIONAL IMPROVEMENT Compared with placebo: Transdermal glyceryl trinitrate may improve mobility at 5–15 days compared with placebo in people with supraspinatus tendinitis (very low-quality evidence).

Benefits

We found no systematic review but found one small RCT (20 people with supraspinatus tendinitis), which compared local transdermal glyceryl trinitrate with placebo. The RCT did not report direct comparisons between the treatment and placebo groups. It found that glyceryl trinitrate significantly reduced pain at 24 hours compared with baseline (mean pain intensities with active treatment measured on a 0–10 analogue scale: 7.1 at baseline, 4.5 at 24 hours, P < 0.001; 2.0 at 48 hours, P < 0.001). Changes in the placebo group were not reported. Relief was maintained after 15 days (figures not available). Mean duration of pain was also significantly reduced with active treatment (figures not available). Mean mobility (assessor rated 4 point scale) significantly improved with active treatment (2.0 at baseline v 0.1 at 5 days; P < 0.0001), but not with placebo (1.2 at baseline v 1.2 at 15 days). The significance figures quoted are not direct comparisons. Significance figures for treatment versus placebo were not reported.

Harms

Headaches were reported in 20% of the treatment group 24 hours after the treatment was started (no comparative figures available).

Comment

None.

Substantive changes

No new evidence

2006; 2006: 1107.
Published online 2006 September 1.

Suprascapular nerve block

Summary

SYMPTOM SEVERITY Compared with placebo: We don’t know whether suprascapular nerve block may relieve shoulder pain compared with placebo ( very low-quality evidence ). FUNCTIONAL IMPROVEMENT Compared with placebo: We don’t know whether suprascapular nerve block may improve shoulder range of movement or function in people with shoulder pain compared with placebo (very low-quality evidence). NOTE We found no direct information about the effects of suprascapular nerve block in the treatment of people with rotator cuff disease.

Benefits

Suprascapular nerve block versus placebo:

We found no systematic review but found three RCTs in people with adhesive capsulitis (frozen shoulder), degenerative shoulder disease, or undergoing shoulder surgery. We found no RCTs specifically in people with rotator cuff disease. The first RCT (34 people with adhesive capsulitis [frozen shoulder]) compared indirect suprascapular nerve block with bupivacaine 0.5% 10 mL versus nerve block with physiological saline 10 mL (placebo) given three times at 7 day intervals. The RCT did not perform an analysis by intention to treat; 11% of people receiving bupivacaine and 30% receiving placebo withdrew from the trial. The RCT found that bupivacaine nerve block significantly reduced pain at 1 month compared with placebo (percentage reduction in pain as measured by the McGill Pain Questionnaire multidimensional pain descriptors score: 64% with bupivacaine v 13% with placebo; P = 0.03). It found no significant difference in shoulder function (percentage improvement in function measured by the 12 point Simple Shoulder test: 16% with bupivacaine v 4% with placebo; P = 0.24). It found no significant difference in shoulder range of movement between groups (percentage improvement as measured by composite score for shoulder motion: 30% with bupivacaine v 43% with placebo; P = 0.67). The second RCT (108 shoulders, 83 people with rheumatoid arthritis and/or degenerative disease of the shoulder) compared nerve block versus subcutaneous saline. The RCT randomised shoulders rather than people. It found that shoulders receiving suprascapular nerve block had significant and clinically important improvements in all pain scores, all disability scores, and some range of movement scores at 1, 4, and 12 weeks compared with shoulders receiving placebo (proportion of shoulders that had improved by ≥ 10 points on the Shoulder Pain and Disability Index [maximum score 100] at 12 weeks: 55% with nerve block v 18% with placebo; P < 0.01, absolute figures not reported; mean change in active abduction at 12 weeks: mean 14.7° with nerve block v 5.1° with placebo; mean difference 9.6°, 95% CI 0.9° to 18.2°). It is unclear whether the results of this trial are generalisable to people with non-arthritic shoulder pain. The third RCT (50 people having ambulatory non-arthroscopic shoulder surgery, all of whom receiving interscalene brachial plexus block) compared adding suprascapular nerve block versus adding placebo. The RCT found that nerve block significantly delayed the time to “first significant pain” compared with placebo (594 minutes with nerve block v 375 minutes with placebo; P = 0.02). The RCT did not define “first significant pain”. The RCT found no significant difference between groups in pain at 24 hours, use of supplemental analgesia, or quality of life outcomes such as patient satisfaction or sleep quality (reported as non-significant, P values not reported, absolute results tabulated).

Harms

Suprascapular nerve block versus placebo:

The first RCT found that some participants had transient dizziness and local tenderness at the injection site (no further data reported). In the second RCT, one person receiving nerve block had chest pain and one receiving placebo had bruising. The third RCT gave no information on adverse effects.

Comment

None.

Substantive changes

New option added on nerve block; categorised as likely to be beneficial.

2006; 2006: 1107.
Published online 2006 September 1.

Intra-articular corticosteroid injections

Summary

SYMPTOM SEVERITY Compared with placebo: Intra-articular corticosteroid injections may be more effective than placebo at relieving pain at 6 weeks, but not at 12 months, in people with adhesive capsulitis ( very low-quality evidence ). Intra-articular corticosteroid injection plus lidocaine compared with lidocaine/placebo: Intra-articular corticosteroid injection may be no more effective at 4–24 weeks than lidocaine or placebo at relieving pain in people with adhesive capsulitis (very low-quality evidence). Compared with physiotherapy: Intra-articular corticosteroid injections seem to be more effective than physiotherapy at relieving pain at 6–7 weeks, but not at 12 months, in people with adhesive capsulitis (very low-quality evidence). Higher doses compared with lower doses: Higher doses of intra-articular corticosteroid injection may be more effective at 6 weeks to 6 months than lower doses at relieving pain in people with frozen shoulder ( low-quality evidence ). FUNCTIONAL IMPROVEMENT Compared with placebo: Intra-articular corticosteroid injections may improve disability and function compared with placebo at 6 weeks, but not at 12 months, in people with adhesive capsulitis (very low-quality evidence). Intra-articular corticosteroid injection plus lidocaine compared with lidocaine: Intra-articular corticosteroid injection may be no more effective at 24 weeks than lidocaine at improving shoulder motion or treatment success in people with adhesive capsulitis (very low-quality evidence). Compared with physiotherapy: Intra-articular corticosteroid injections seem to be more effective than physiotherapy at improving disability at 6–7 weeks, but not at 12 months, in people with adhesive capsulitis (very low-quality evidence). Higher doses compared with lower doses: Higher doses of intra-articular corticosteroid injections may reduce functional impairment and movement restriction at 6 weeks to 6 months in people with frozen shoulder compared with lower doses (low-quality evidence).

Benefits

Intra-articular corticosteroid injections versus placebo:

We found no systematic review, but found two RCTs. The first RCT (93 people with adhesive capsulitis [frozen shoulder]) compared four treatments: intra-articular corticosteroid injection (40 mg triamcinolone hexacetonide under fluoroscopic control) plus physiotherapy; corticosteroid injection alone; saline injection plus physiotherapy; and saline injection alone. It found that intra-articular corticosteroids (with or without physiotherapy) significantly improved pain and disability at 6 weeks compared with placebo, but found no significant difference at 12 months (improvement in shoulder pain and disability index score at 6 weeks: 46.5 with corticosteroid plus physiotherapy v 36.7 with corticosteroid alone v 18.9 with placebo; P = 0.0004 for both corticosteroid treatments v placebo; at 12 months: 48.3 with corticosteroid plus physiotherapy v 50.1 with corticosteroid alone v 47.2 with placebo; P value not reported). <START>The second RCT (80 people with adhesive capsulitis of less than 6 months' duration) compared four interventions: injection of triamcinolone 20 mg versus placebo with or without physiotherapy. All participants were given an identical home exercise programme. Outcome measures were assessed at 6 weeks and 16 weeks. The primary outcome measure was the Shoulder Disability Questionnaire score. Secondary outcomes were measurement of pain using a visual analogue scale, global disability using the visual analogue scale, and range of passive external rotation. The RCT did not directly compare corticosteroid injection versus physiotherapy; instead, it performed a two way analysis of variance to assess the effects of each intervention separately. It found that corticosteroids significantly improved disability and self assessment of global disability at 6 weeks compared with no corticosteroids (mean change from baseline in Shoulder Disability Questionnaire: –6.9 with triamcinolone v –3.3 with no triamcinolone; global visual analogue scale: –33.4 with triamcinolone v –21.8 with no triamcinolone; P = 0.004 for both outcomes). There was no significant difference in the other measured outcomes (P > 0.05). At 16 weeks, all groups had improved to a similar degree with respect to all outcome measures.<END>

Intra-articular corticosteroid injections plus lidocaine versus lidocaine alone:

We found one systematic review (search date 2002, 2 RCTs). The first RCT identified by the review (48 people with adhesive capsulitis) compared four treatments: intra-articular methylprednisolone plus lidocaine; intra-articular lidocaine; intrabursal methylprednisolone plus lidocaine; and intrabursal lidocaine. It found no significant difference between intra-articular methylprednisolone plus lidocaine and lidocaine alone in pain score or shoulder motion at 24 weeks (pain on 6 point pain scale [0 = no pain; 5 = most severe]: improvement of about 1 in point both groups [absolute score about 3 in both groups], P > 0.05; shoulder motion: improvement of about 50° in both groups [absolute range of movement about 350° in both groups], P > 0.05). The second RCT in the review (60 people with rotator cuff lesions, 12 in each treatment group) compared five treatments: tolmetin plus methyl prednisolone plus lidocaine; methylprednisolone plus lidocaine; acupuncture; ultrasound; and placebo. It found no significant difference between intra-articular injection and placebo in pain or treatment success at 4 weeks (pain on a 100 mm visual analogue scale: 29.2 mm with intra-articular injection v 22.0 mm with placebo; P value not reported). These two RCTs may have been too small to detect a clinically important difference.

Combined intra-articular and subacromial corticosteroid injections:

See benefits of subacromial corticosteroid injection.

Intra-articular corticosteroid injections versus physiotherapy:

We found one systematic review (search date 2002, 1 RCT) and one subsequent RCT. The RCT identified by the review (109 people with adhesive capsulitis) compared up to three injections of 40 mg intra-articular triamcinolone acetonide versus 12 physiotherapy sessions over 6 weeks. It found that steroid injection significantly increased success rates at 7 weeks compared with physiotherapy, but the difference in severity score was less significant at 52 weeks (success, defined as complete recovery or much improved at 7 weeks: 40/52 [77%] with corticosteroids v 26/56 [46%] with physiotherapy; RR 1.66, 95% CI 1.21 to 2.28; mean improvement in severity score at 52 weeks: 70 with corticosteroids v 59 with physiotherapy; difference 11, 95% CI 1 to 23). The first subsequent RCT (93 people with adhesive capsulitis) compared four treatments: 40 mg intra-articular triamcinolone hexacetonide under fluoroscopic control plus physiotherapy; corticosteroid injection alone; saline injection plus physiotherapy; and saline injection alone. It found that corticosteroid alone significantly improved pain and disability at 6 weeks compared with physiotherapy alone, but found no significant difference at 12 months (improvement in shoulder pain and disability index score at 6 weeks: 36.7 with corticosteroid alone v 22.2 with physiotherapy alone, P < 0.05; at 12 months: 50.1 with corticosteroid alone v 45.5 with physiotherapy alone, P value not reported).

Harms

Intra-articular injections are rarely associated with infection (estimated at 1/14 000 to 1/50 000 injections). Acute self limited synovitis was reported in up to 2% of people. Prevalence of tendon rupture, including rupture of the bicipital tendon and rotator cuff, was reported in less than 1% of people after local injection of corticosteroids. Subcutaneous fat necrosis or skin atrophy was found in less than 1%. Corticosteroid arthropathy and osteonecrosis were rare (< 0.8%) and seemed to affect mostly weight bearing joints.

Combined intra-articular and subacromial corticosteroid injections:

See harms of subacromial corticosteroid injections.

Intra-articular corticosteroid injections versus physiotherapy:

The RCT identified by the systematic review compared corticosteroid injection versus physiotherapy in painful stiff shoulders, and reported that corticosteroids were associated with more facial flushing (9/52 [17%] people treated with corticosteroid injections v 1/56 [2%] treated with physiotherapy) and more new menstrual irregularities (6/52 [12%] people treated with local corticosteroid injections v 0/56 [0%] after physiotherapy). Both treatments were associated with fever during treatment (7% of people with corticosteroid injection v 2% having physiotherapy) and local skin irritation (2% with corticosteroid v 3.5% with physiotherapy). People having physiotherapy had tingling, radiation of pain down the arm, or slight swelling after treatment (7%) whereas people having corticosteroid injections had sweating, fatigue, dry mouth, dizziness, or headache (11%). The subsequent RCT comparing corticosteroid with and without physiotherapy versus placebo gave no information on adverse effects.

Comment

Few RCTs of interventions in shoulder pain used high quality methods. One case control study found that clinical outcome correlated with accuracy of injection. Another case control study found that only 10% of intra-articular injections were placed correctly, even by experienced operators. Confirmation of injection accuracy can be obtained with fluoroscopy or ultrasound.

Different doses:

We found one RCT (57 people with frozen shoulder). It found that higher dose (40 mg) compared with lower dose (10 mg) triamcinolone injection significantly reduced pain after 6 weeks (change on 100 mm visual analogue scale: 31 mm with low dose v 49 mm with high dose, CI not reported; P < 0.01), movement restriction, and self rated functional impairment (change on 4 point ordinal scale: 0.7 with low dose v 1.3 with high dose, CI not reported; P = 0.03), but did not significantly improve sleep disturbance. The RCT found no significant difference in any outcome after 6 months.

Substantive changes

Intra-articular corticosteroid injections One RCT added; categorisation unchanged (unknown effectiveness)

2006; 2006: 1107.
Published online 2006 September 1.

Intra-articular guanethidine

Summary

SYMPTOM SEVERITY Compared with placebo: Intra-articular guanethidine may reduce pain at 8 weeks compared with placebo in people with arthritic shoulder pain ( very-low quality evidence ). FUNCTIONAL IMPROVEMENT Compared with placebo: Intra-articular guanethidine may improve range of movement at 8 weeks compared with placebo in people with arthritic shoulder pain (very-low quality evidence). NOTE We found no direct information about the effects of intra-articular guanethidine in people with non-arthritic shoulder pain.

Benefits

We found no systematic review or RCTs of intra-articular guanethidine in people with shoulder pain. We found one RCT (18 people with resistant shoulder pain, including 6 people with rheumatoid arthritis, 5 with osteoarthritis, 1 with psoriatic arthritis, 5 with adhesive capsulitis [frozen shoulder], and 1 with rotator cuff tendinitis) comparing intra-articular guanethidine versus intra-articular saline. It found that guanethidine significantly reduced pain compared with placebo after 8 weeks but found no significant difference in the range of movement (pain improvement on a 10 cm visual analogue scale: 36% with guanethidine v 16% with placebo, P < 0.05; range of abduction: 53° at baseline and 52° at 8 weeks with guanethidine v 57° at baseline and 56° at 8 weeks with placebo, CI not reported). It is unclear whether the results of this trial are generalisable to people with non-arthritic shoulder pain.

Harms

We found no RCTs.

Comment

None.

Substantive changes

No new evidence

2006; 2006: 1107.
Published online 2006 September 1.

Intra-articular NSAID injections

Summary

We found no direct information about the effects of intra-articular NSAID injections in people with shoulder pain.

Benefits

We found no systematic review or RCTs evaluating intra-articular injection of NSAIDs.

Harms

We found no RCTs.

Comment

None.

Substantive changes

No new evidence

2006; 2006: 1107.
Published online 2006 September 1.

Subacromial corticosteroid injections

Summary

SYMPTOM SEVERITY Subacromial corticosteroid injections plus lidocaine compared with lidocaine: We don’t know whether subacromial corticosteroid injections plus lidocaine relieve pain or reduce severity scores compared with lidocaine in people with shoulder pain ( very-low quality evidence ). Subacromial corticosteroid injections plus bupivacine compared with bupivacaine: Subacromial corticosteroid injections plus bupivacine may be no more effective at 3–12 weeks than bupivacaine at relieving pain in people with post-traumatic impingement of the shoulder (very low-quality evidence). Subacromial corticosteroid injections plus intra-articular corticosteroid injections compared with placebo: We don’t know whether combined subacromial corticosteroid injections and intra-articular corticosteroid injections relieve pain compared with placebo in people with shoulder pain (very-low quality evidence). FUNCTIONAL IMPROVEMENT Subacromial corticosteroid injections plus lidocaine may be no more effective than lidocaine at improving function, range of movement, or activities of daily living in people with shoulder pain (very-low quality evidence). Subacromial corticosteroid injections plus bupivacine compared with bupivacaine: Subacromial corticosteroid injections plus bupivacine may be no more effective at 3–12 weeks than bupivacaine at improving active shoulder abduction in people with post-traumatic impingement of the shoulder (very low-quality evidence). Subacromial corticosteroid injections plus intra-articular corticosteroid injections compared with placebo: We don’t know whether combined subacromial corticosteroid injections and intra-articular corticosteroid injections improve function and active shoulder abduction in people with shoulder pain compared with placebo (very-low quality evidence). Subacromial corticosteroid injection plus lidocaine compared with physiotherapy: Subacromial corticosteroid injection plus lidocaine may be no more effective at 6 months than physiotherapy at improving disability scores in people with a new episode of unilateral shoulder pain, but may increase the need for repeat consultation or other interventions ( low-quality evidence ). NOTE We found no direct information about whether subacromial corticosteroid injections are better than no active treatment.

Benefits

Subacromial corticosteroid injections versus placebo:

We found one systematic review, which identified no RCTs.

Subacromial corticosteroid injections plus lidocaine versus lidocaine alone:

We found one systematic review (search date 2002, 4 RCTs). The first RCT identified by the review (50 people with rotator cuff tendinitis) compared three treatments: subacromial triamcinolone plus lidocaine (1 mL of 80 mg/mL triamcinolone plus 2 mL of 0.5% lidocaine); subacromial lidocaine (3 mL of 0.5%); and oral diclofenac plus subacromial lidocaine (diclofenac 50 mg 3 times a day plus 3 mL of 0.5% lidocaine). It found that subacromial triamcinolone plus lidocaine significantly increased clinical response rates at 4 weeks compared with lidocaine alone, but it found no significant difference in pain (clinical response, defined as improvement in a combination of overall pain severity score, range of active abduction, and limitation of function: 70% with triamcinolone plus lidocaine v 0% with lidocaine alone; P < 0.001; reduction in pain: WMD + 7 cm, 95% CI –33 cm to + 47 cm). The second RCT identified by the review (55 people with rotator cuff tendinitis) found no significant difference between subacromial methylprednisolone (40 mg) plus lidocaine (1 mL of 1%) and lidocaine alone for pain or remission rate at 12 weeks (pain using visual analogue scale 0–30: median pain improved by 8 points with active treatment v 8 points with placebo, P value not reported; remission, defined as score of 0 on pain, active abduction, flexion, and external rotation: 32% in remission with corticosteroids v 26% with placebo, P value not reported). The third RCT in the review (published in abstract form only; 52 people with rotator cuff tendinitis or partial tear, of whom results for 41 people reported) found no significant difference between lidocaine (4 mL of 2%) plus betamethasone (1 mL of 6 mg/mL) and lidocaine (5 mL of 2%) alone for clinical response at 6 months (response rate, measured by American Shoulder and Elbow Surgeons criteria: P = 0.77; no further data reported). The fourth RCT in the review (40 people with subacromial impingement who received physiotherapy) found that triamcinolone acetonide (2 mL of 40 mg/mL) plus lidocaine (4 mL of 1%) significantly reduced pain compared with lidocaine alone (6 mL of 1%), but found no significant difference in activities of daily living after a mean follow up of about 30 weeks (moderate or severe pain: 3/19 [16%] with corticosteroid plus lidocaine v 15/21 [71%] with lidocaine alone; P value not reported). Loss to follow up was not clear, and it was not clear whether analysis was by intention to treat. The timing of follow up ranged from 12–55 weeks.

Subacromial corticosteroid injections plus bupivacaine versus bupivicaine alone:

We found one RCT (98 people with persistent, post-traumatic impingement of the shoulder) comparing subacromial methylprednisolone (40 mg) plus bupivacaine (2 mL of 0.5%) versus bupivacaine alone. It found no significant difference in pain scores at 3, 6, or 12 weeks (pain measured on a 10 cm visual analogue scale at 12 weeks: 1.38 cm in both groups; P = 0.99). It also found no significant difference in active shoulder abduction at 3, 6, or 12 weeks (mean active abduction at 12 weeks: 168.9° with corticosteroid plus bupivacaine v 170.3° with bupivacaine alone; P = 0.8).

Combined subacromial and intra-articular corticosteroid injections:

We found one systematic review (search date 2002, 2 RCTs ). The first RCT (100 people with pain or tenderness over the supraspinatus during the preceding 3 months) compared four treatments: subacromial plus intra-articular triamcinolone plus lidocaine plus oral naproxen; subacromial plus intra-articular triamcinolone plus lidocaine; subacromial plus intra-articular lidocaine plus oral naproxen; and placebo (subacromial plus intra-articular lidocaine alone). Doses used in this study were: 1 mL of 40 mg/mL triamcinolone; 3–4 mL of 1% lidocaine; and 500 mg naproxen. The RCT found that people having subacromial plus intra-articular triamcinolone plus lidocaine had higher remission rates compared with placebo at 4 weeks (remission, defined as a perfect score in active abduction, pain, and limitation of function: 28% with triamcinolone v 8% with placebo; P value not reported). The second RCT in the review (42 people with adhesive capsulitis and night pain) compared four treatments: subacromial plus intra-articular corticosteroid (methylprednisolone 20 mg plus lidocaine 0.5 mL of 1%, by each route); mobilisation; ice therapy; and no treatment. It found no significant difference among treatment groups at 6 months (no data reported).

Subacromial corticosteroid injections plus lidocaine versus physiotherapy:

We found one RCT (207 people attending their physician with a new episode of unilateral shoulder pain). It found no significant difference between subacromial methylprednisolone (40 mg) plus lidocaine (4 mL of 1%) and physiotherapy (8 sessions over 6 weeks) in disability or successful outcome at 6 months (disability, measured on the validated shoulder disability questionnaire from 0 [no disability] to 23 [severe disability]: mean difference + 1.4, 95% CI –0.2 to + 3.0; successful outcome, defined as 50% drop in disability score from baseline: 53% with injection v 60% with physiotherapy; difference + 7%, 95% CI –6.8% to + 20.4%). It found that corticosteroid injection significantly increased the combined outcome of need for repeat consultation or other intervention for shoulder pain compared with physiotherapy (57% v 40%; difference 17%, 95% CI 4% to 31%).

Harms

Subacromial corticosteroid injections versus placebo:

We found one systematic review, which identified no RCTs.

Subacromial corticosteroid injections plus lidocaine versus lidocaine alone:

The first RCT included in the review (50 people with rotator cuff tendinitis) found no adverse effects with subacromial corticosteroid plus lidocaine compared with lidocaine alone, apart from mild discomfort.

Combined intra-articular and subacromial corticosteroid injections:

One RCT (50 people with rotator cuff tendinitis receiving treatments of interest) identified by the review found similar rates of adverse effects with subacromial plus intra-articular corticosteroid injection and with placebo (3/25 [12%; mild gastrointestinal symptoms; pityriasis rosea 2 days after the injection; increased frequency of urination] with corticosteroid injection v 3/25 [12%; mild gastrointestinal symptoms; diarrhoea; vasovagal reaction] with placebo).

Comment

Range of movement is not a satisfactory surrogate measure of function. We found no evidence on the accuracy of placement of subacromial injections.

Substantive changes

No new evidence

2006; 2006: 1107.
Published online 2006 September 1.

Extracorporeal shock wave therapy

Summary

SYMPTOM SEVERITY Compared with placebo: Extracorporeal shock wave therapy (ESWT) may relieve pain and reduce calcification in people with calcific tendinitis compared with placebo ( very low-quality evidence ). High-energy ESWT seems superior compared with low-energy ESWT. ESWT compared with sham treatment: ESWT is no more effective at 3–6 months than sham treatment at relieving pain in people with chronic non-calcific rotator cuff tendinopathy ( moderate-quality evidence ). Two sessions compared with one session: Two sessions of ESWT are no more effective than one session at providing continuous pain relief (moderate-quality evidence). FUNCTIONAL IMPROVEMENT Compared with placebo: ESWT may improve shoulder function in people with calcific tendinitis compared with placebo (very low-quality evidence). ESWT compared with sham treatment: ESWT is no more effective at 12 weeks than sham treatment at improving shoulder function in people with chronic non-calcific rotator cuff tendinopathy (moderate-quality evidence). NOTE ESWT can be painful during treatment.

Benefits

We found no systematic review but found five RCTs, three in people with calcific tendinitis and two in people with non-calcific rotator cuff tendinopathy.

Calcific tendinitis:

The first RCT (115 people with calcific tendinitis) compared three different extracorporeal shock wave therapy (ESWT) regimens (low energy treatment in a single session v a single high energy session v 2 high energy sessions 1 week apart) versus no treatment. The results of this trial should be interpreted with caution because of the high withdrawal rate and lack of an intention to treat analysis. It found that high energy treatment significantly increased subjective improvement of pain compared with low energy treatment or placebo at 3 months (81 people analysed; AR for improvement 14/20 [70%] with 2 high energy sessions v 12/20 [60%] with 1 high energy session v 6/21 [29%] with low energy treatment v 0/20 [0%] with placebo; NNT 2, 95% CI 1 to 21 for high energy treatment compared with placebo with single session treatment and NNT 2, 95% CI 1 to14 with 2 session treatment). It also found that high energy treatment significantly improved a combined measure of pain and function in activities of daily living compared with placebo (the Constant and Murley score difference; P < 0.0001). The second RCT (144 people with calcific tendinitis) compared three interventions: high energy ESWT, low energy ESWT, and sham ESWT. People having high and low ESWT received the same cumulative energy dose. Treatment was given in two treatment sessions, approximately 2 weeks apart, followed by physiotherapy. The RCT found that both high energy and low energy ESWT significantly reduced pain and improved activities of daily living, range of motion, and power at 6 months compared with sham treatment (measured by Constant and Murley scores: mean 31.0 [95% CI 26.7 to 35.3 with high energy ESWT] v 15.0 [95% CI 10.2 to 19.8 with low energy ESWT] v 6.6 [95% CI 1.4 to 11.8 with sham treatment]; P < 0.001 for both active treatments v sham treatment). Similar improvements in pain with high or low energy ESWT were also found at 3 and 12 months, as well as similar improvements in self rated pain and radiographic changes at 3, 6, and 12 months. The third RCT (90 people with clearly circumscribed and dense calcific tendinitis of 1 shoulder) also compared three interventions: high energy ESWT at two levels (E1  = 0.15 mJ/mm2 or E2  = 0.44 mJ/mm2 ) and sham treatment. Treatment was given at 6 weekly intervals until symptoms resolved, five treatments had been given, or the participant withdrew from the trial. All participants receiving high energy ESWT completed the trial. The trial did not directly compare ESWT versus sham treatment. It found that people receiving lower level ESWT (E1  = 0.15 mJ/mm2 ) had significantly less pain during treatment but significantly more treatments than people receiving higher level therapy (E2  =0.44 mJ/mm2 ; P < 0.001 for both outcomes). It found that people receiving lower level ESWT had residual calcification and that 87% had recurrence of pain. People receiving high level ESWT had no residual calcification or recurrence of pain. Sham treatment had no effect on resolution of calcification or reduction in pain.

Non-calcific rotator cuff tendinopathy:

The first RCT (74 people with chronic non-calcifying rotator cuff tendinitis) found no significant difference between ESWT (1500 pulses at 0.12 mJ/mm) and sham treatment (3 sessions at monthly intervals) in shoulder pain or night pain at 3 or 6 months (improvement of 50% from baseline for shock wave therapy versus sham at 3 months on the shoulder pain and disability index: OR 1.76, 95% CI 0.08 to 0.71; night pain: OR 0.94, 95% CI 0.65 to 1.36). The RCT may have lacked power to exclude clinically important effects. The second RCT (40 people with chronic suprapinatus tendinosis, 38 analysed) found no significant difference between ESWT (6000 pulses at 0.11 mJ/mm) and sham treatment (2 sessions weekly for 3 weeks) in function or pain at 12 weeks (difference treatment v control: pain at rest on 10 point visual analogue scale + 1.4, 95% CI –1.0 to + 3.9; pain during activity on 10 point scale: + 2.50, 95% CI –0.81 to + 3.33). The RCT may have lacked power to exclude clinically important effects.

Harms

Extracorporeal shock wave therapy (ESWT) can be painful during treatment.

Calcific tendinitis:

Small haematomas were reported in the first RCT, but the incidence was not stated and they could have been related to subcutaneous infiltration of local anaesthetic before treatment. The second RCT found that 20/44 (45%) people receiving high energy ESWT had moderate pain and 16/44 (36%) had severe pain during treatment. It also found that 22/46 (49%) people receiving low energy ESWT had moderate pain and 5/46 (11%) had severe pain; no other adverse effects were reported. People in the third RCT also developed haematomas of 2 cm or more (2 people having lower level and 6 people having higher level ESWT), but no other adverse effects were reported.

Non-calcific rotator cuff tendinopathy:

In the first RCT, three people withdrew from the trial because of pain during treatment. The second RCT gave no information on adverse effects.

Comment

The mechanism of action of extracorporeal shock wave therapy (ESWT) remains unclear. Technical factors and the dosing regimen of shockwave administration are likely to be important to clinical outcome. However, the first RCT found no significant difference between two sessions and a single session of ESWT in continued pain (91 people analysed; 23/49 [47%] with 2 sessions v 23/42 [55%] with 1 session; RR of continued pain 0.85, 95% CI 0.50 to 1.23).

Substantive changes

No new evidence

2006; 2006: 1107.
Published online 2006 September 1.

Laser treatment

Summary

SYMPTOM SEVERITY Compared with placebo: Laser treatment may reduce pain and increase recovery rates at 1 month compared with placebo in people with rotator cuff tendinitis ( very low-quality evidence ).

Benefits

Laser treatment versus placebo:

We found one systematic review (search date 2002, 4 RCTs) and one additional RCT. The first RCT in the review (35 people with rotator cuff tendinitis) found no significant difference between continuous irradiation laser and sham laser (10 minute sessions, twice weekly for 8 weeks) for pain or abduction at 8 weeks (pain on 10 cm visual analogue scale: improved by 3.6 cm with laser v 1.2 cm with placebo, P = 0.34; range of movement: improved by 36° with laser v 29° with placebo; P = 0.23). The second RCT in the review (20 people with rotator cuff tendinitis) compared three treatments: low level infrared laser (5 minutes, 3 times weekly, for 2 weeks); sham laser; and naproxen. It found that laser significantly reduced pain after 2 weeks compared with sham laser (pain score difference on 10 cm visual analogue scale: 2.5%, 95% CI 2.0% to 3.0%). The third RCT in the review (24 people with supraspinatus tendinitis) found that low level laser (9 treatments over a 3 week period) significantly improved pain at 3 weeks compared with sham laser (pain improved: 80% with laser v 20% with sham laser; P < 0.05). A fourth RCT in the review (40 people with shoulder periarthritis) compared 15 laser treatments with sham laser and is awaiting translation. The additional RCT (91 people with rotator cuff tendinitis) found that laser significantly increased recovery rates at 1 month compared with placebo (42/47 [89%] v 18/44 [41%]; ARR 48%, 95% CI 31% to 65%).

Harms

None of the RCTs included in the review assessed the adverse effects of laser therapy.

Comment

The quality of studies on the effects of laser treatment in shoulder disorders is limited by the lack of standardised approaches.

Substantive changes

No new evidence

2006; 2006: 1107.
Published online 2006 September 1.

Physiotherapy (manual treatment, exercises)

Summary

SYMPTOM SEVERITY Physiotherapy plus home exercises compared with no treatment: Physiotherapy plus home exercises may improve function and increase recovery times at 4 weeks in people with mixed shoulder disorders compared with no treatment ( low-quality evidence ). Compared with sham laser: Physiotherapy may improve Neer scores (pain, function, active range of movement, and anatomical or radiological examination) at 6 months and at 2.5 years in people with rotator cuff disease compared with sham laser (low-quality evidence). Maitland mobilisation compared with other treatments: Maitland mobilisation may be no more effective at 3 months at relieving pain in people with adhesive capsulitis and night pain compared with subacromial pus intra-articular corticosteroid injections, ice therapy, and no treatment ( very low-quality evidence ). Home exercises plus oral corticosteroids compared with home exercises alone: Home exercises may not reduce pain at 8 months in people with adhesive capsulitis compared with oral corticosteroids plus advice on home pendular exercises (very low-quality evidence). Compared with intra-articular corticosteroid injections: Physiotherapy seems less effective at 6–7 weeks, but not at 12 months, at relieving pain in people with adhesive capsulitis compared with intra-articular corticosteroid injections (very low-quality evidence). FUNCTIONAL IMPROVEMENT Maitland mobilisation compared with other treatments: Maitland mobilisation may not improve range of motion at 3 months in people with adhesive capsulitis and night pain compared with subacromial pus intra-articular corticosteroid injections, ice therapy, and no treatment (very low-quality evidence). Compared with intra-articular corticosteroid injections: Physiotherapy seems less effective at 6–7 weeks, but not at 12 months, at improving disability in people with adhesive capsulitis compared with intra-articular corticosteroid injections (very low-quality evidence). Compared with subacromial corticosteroid injection plus lidocaine: Physiotherapy may not improve disability scores at 6 months in people with a new episode of unilateral shoulder pain compared with subacromial corticosteroid injection plus lidocaine, but may reduce the need for repeat consultation or other interventions (low-quality evidence). Compared with surgical arthroscopic decompression: Supervised exercises may not improve Neer scores (pain, function, active range of movement, and anatomical or radiological examination) at 6 months and at 2.5 years in people with rotator cuff disease compared with surgical arthroscopic decompression (low-quality evidence).

Benefits

Physiotherapy versus placebo or no treatment:

We found one systematic review (search date 2002, 3 RCTs) and one subsequent RCT. The first RCT identified by the review (66 people with mixed shoulder disorders) found that physiotherapy plus home exercises significantly increased recovery and improved function at 4 weeks compared with no treatment (recovery: RR 7.74, 95% CI 1.97 to 30.32; improved function: RR 1.53, 95% CI 0.98 to 2.39). The second RCT identified by the review (125 people with rotator cuff disease) compared three treatments: exercise supervised by an experienced physiotherapist plus home exercises plus pain management; arthroscopic decompression plus physiotherapy; and sham laser over 6 weeks. It found that physiotherapy significantly improved the Neer score compared with sham laser at 6 months (median Neer score: 86 with physiotherapy v 66 with sham laser; P < 0.001). Long term follow up of 110 participants from the RCT found that physiotherapy significantly increased the success rate compared with sham laser at 2.5 years (success, defined as Neer score > 80: 27/44 [61%] with physiotherapy v 7/28 [25%] with sham laser; P < 0.01). The third small RCT identified by the review (42 people with adhesive capsulitis and night pain) compared four treatments: subacromial plus intra-articular corticosteroid; Maitland mobilisation; ice therapy; and no treatment. It found no significant difference in pain or range of motion between treatment groups at 3 months (no data reported). The RCT may have lacked power to detect a clinically important difference. The subsequent RCT (80 people with adhesive capsulitis of less than 6 months' duration) compared four interventions: injection of triamcinolone 20 mg versus placebo, with or without physiotherapy. All participants were given an identical home exercise programme. Outcome measures were assessed at 6 weeks and 16 weeks. The primary outcome measure was Shoulder Disability Questionnaire score. Secondary outcomes were measurement of pain using a visual analogue scale, global disability using a visual analogue scale, and range of passive external rotation. The RCT did not directly compare physiotherapy versus corticosteroid injection; instead, it performed a two way analysis of variance to assess the effects of each intervention separately. It found that physiotherapy significantly improved passive external rotation at 6 weeks compared with no physiotherapy (18.7 with physiotherapy v 10.4 with no physiotherapy; P = 0.02), but there was no significant difference in other measured outcomes (P > 0.05). At 16 weeks, all groups had improved to a similar degree with respect to all outcome measures.

Physiotherapy versus surgical arthroscopic decompression:

See benefits of surgical arthroscopic compression.

Physiotherapy versus intra-articular corticosteroids:

See benefits of intra-articular corticosteroids.

Home exercise plus oral corticosteroids versus home exercise alone:

See benefits of oral corticosteroids.

Physiotherapy versus subacromial corticosteroid injections:

See benefits of subacromial corticosteroid injections.

Harms

Physiotherapy versus placebo or no treatment:

The systematic review and RCTs gave no information on adverse effects.

Physiotherapy versus surgical arthroscopic decompression:

See harms of surgical arthroscopic decompression.

Physiotherapy versus intra-articular corticosteroids:

See harms of intra-articular corticosteroids.

Oral corticosteroids plus home exercise versus home exercise alone:

See harms of oral corticosteroids.

Physiotherapy versus subacromial corticosteroid injections:

See harms of subacromial corticosteroid injections.

Comment

Studies on the effects of physiotherapy in shoulder disorders are limited by the lack of standardised approaches. Diverse disorders are considered under the universal term “shoulder pain”, diverse forms of physiotherapy have been evaluated, and outcome measures and follow up periods vary.

Substantive changes

Physiotherapy (manual treatment, exercises) One RCT added; categorisation unchanged (likely to be beneficial)

2006; 2006: 1107.
Published online 2006 September 1.

Electrical stimulation

Summary

SYMPTOM SEVERITY Compared with sham electrical stimulation: Electrical stimulation may improve calcific tendinitis at 6 weeks in people with shoulder pain compared with sham electrical stimulation ( very low-quality evidence ).

Benefits

Electrical stimulation versus sham electrical stimulation:

We found one systematic review (search date 2002, 3 RCTs). The first RCT in the review (180 people with pain over deltoid or reduced movement not improved by 6 exercise sessions) compared electrical stimulation (bipolar interferential electrical stimulation) with sham electrical stimulation, and compared pulsed ultrasound with sham ultrasound in a blinded two by two factorial design (see benefits of ultrasound). It found no significant difference in the proportion of people who reported a “large improvement” at 6 weeks (AR 17/73 [23%] with electrical stimulation v 16/72 [22%] with control; ARR + 1%, 95% CI –13% to + 15%). The second RCT in the review (60 people with symptomatic calcific tendinitis) found that pulsed electromagnetic field significantly improved calcific tendinitis at 6 weeks compared with sham treatment (see comment). The third RCT in the review (29 people with rotator cuff tendinitis not cured by corticosteroid injection) compared electrical stimulation induced by pulsed electromagnetic fields (5–9 hours/day for 4 weeks) versus placebo, but it did not report on clinical improvement or resolution.

Harms

The review gave no information on adverse effects.

Comment

The quality of studies on the effects of electrical treatments in shoulder disorders is limited by the lack of standardised approaches. We found no good evidence that different forms of electrical stimulation produce different effects. Further details of the outcomes in the second RCT in the review should be available when this RCT is translated.

Substantive changes

No new evidence

2006; 2006: 1107.
Published online 2006 September 1.

Ice

Summary

SYMPTOM SEVERITY Compared with other treatments: Ice therapy may not relieve pain at 3 months in people with adhesive capsulitis and night pain compared with subacromial pus intra-articular corticosteroid injections, Maitland mobilisation, and no treatment ( very low-quality evidence ). FUNCTIONAL IMPROVEMENT Compared with other treatments: Ice therapy may not improve range of motion at 3 months in people with adhesive capsulitis and night pain compared with subacromial pus intra-articular corticosteroid injections, Maitland mobilisation, and no treatment (very low-quality evidence).

Benefits

We found one small RCT (42 people with adhesive capsulitis and night pain), which compared four treatments: subacromial plus intra-articular corticosteroid; Maitland mobilisation; ice therapy; and no treatment. It found no significant difference in pain or range of motion between treatment groups at 3 months (no data reported). However, the study may have lacked power to detect the clinically important effects of treatment.

Harms

The RCT gave no information on adverse effects.

Comment

None.

Substantive changes

No new evidence

2006; 2006: 1107.
Published online 2006 September 1.

Multidisciplinary biopsychosocial rehabilitation

Summary

SYMPTOM SEVERITY Compared with usual care: Mutidisciplinary biopsychosocial rehabilitation (physiotherapy with psychological, behavioural, and educational Interventions) may not improve symptoms or function in people with chronic neck and shoulder pain compared with usual care ( very low-quality evidence ).

Benefits

We found one systematic review (search date 2002). If identified no good quality RCTs solely in people with shoulder pain of multidisciplinary biopsychosocial rehabilitation compared with usual treatment. It identified one low quality RCT (70 people aged 20–55 years) in people with chronic neck and shoulder pain. Co-interventions were not avoided, blinding of therapists was not specified, analysis was not by intention to treat, and treatment groups were dissimilar at baseline. It found no significant difference for multidisciplinary biopsychosocial rehabilitation versus usual treatment. The rehabilitation combined physiotherapy with psychological, behavioural, and educational interventions.

Harms

We found no reliable RCTs.

Comment

None.

Substantive changes

No new evidence

2006; 2006: 1107.
Published online 2006 September 1.

Ultrasound

Summary

SYMPTOM SEVERITY Compared with placebo: Ultrasound may not relieve pain at 4 weeks to 12 months in people with shoulder pain compared with placebo ( very low-quality evidence ). FUNCTIONAL IMPROVEMENT Compared with placebo: Ultrasound may not improve function or range of movement at 4 weeks to 12 months in people with shoulder pain compared with placebo (very low-quality evidence).

Benefits

Ultrasound versus placebo or no treatment:

We found one systematic review (search date 2002, 5 RCTs). The review included studies in people with different clinical conditions. The first RCT in the review (70 shoulders in 63 people with calcific tendinitis) compared pulsed ultrasound (frequency 890 Hz; intensity 2.5 W/cm2 ; pulsed mode 1 : 4) versus sham treatment over the area of calcification. The first 15 treatments were given daily (5 times weekly) and the remainder three times weekly for 3 weeks. The treating therapist was blind to treatment allocation. Nine people (9 shoulders) did not complete the treatment: three in the ultrasound group and six in the sham group, two in the latter because of pain. The RCT found that ultrasound significantly improved pain and quality of life at the end of treatment (6 weeks) but found no significant difference at 9 months (6 weeks: mean improvement in 15 point pain score was 6.4 with ultrasound v 1.6 with sham, P < 0.001; mean improvement in 10 point quality of life score: 2.6 with ultrasound v 0.4 with sham, P = 0.002; 9 months: mean improvement in 15 point pain score: 5.7 points with ultrasound v 4.0 points with sham, P = 0.23; mean improvement in 10 point quality of life score: 2.4 with ultrasound v 1.9 with sham, P = 0.52). The second RCT in the review (180 people with either pain over deltoid on movement or reduced range of shoulder movement, who had failed to respond to 6 sessions of exercise) compared five treatments: pulsed ultrasound; sham ultrasound; bipolar interferential electrical stimulation; sham electrical stimulation; and sham electrical stimulation plus sham ultrasound. The RCT assessed recovery using a 7 point Likert scale scored from “very large improvement, including recovery” to “very much worse”. It found no significant difference in the proportion rating themselves as “very large improvement” between ultrasound and either no treatment or sham ultrasound at 6 weeks (26% with ultrasound v 19% with sham ultrasound, difference + 7%, 95% CI –7% to + 20%; 26% with ultrasound v 20% with no treatment, difference + 6%, 95% CI –16% to + 17%). Similarly, it found no significant difference between ultrasound and control in functional status, pain, or range of movement after 12 months. The third RCT in the review (60 people with rotator cuff lesions) compared five treatments: ultrasound (no details reported); tolmetin plus methylprednisolone plus lidocaine; methylprednisolone plus lidocaine; acupuncture; and placebo. It found no significant difference between ultrasound and placebo in pain or treatment success at 4 weeks, although the study may have lacked power to detect clinically important differences (mean pain score on a 100 mm visual analogue scale from baseline to 4 weeks: 48.2 to 41.2 with ultrasound v 52.2 to 22.0 with placebo; P value not reported). The fourth RCT in the review (20 people with shoulder pain and limited movement for > 1 month) found similar proportions of people with either minimal or no pain after 4 weeks with ultrasound (1 MHz, 1.2 W/cm2, for 6 minutes) compared with sham ultrasound, although the study may have lacked power to detect clinically important effects (7/11 [64%] with ultrasound v 4/9 [44%] with placebo; P value not reported). The fifth RCT in the review (61 people with rotator cuff disease without tear) found no significant difference between pulsed ultrasound (1.0 MHz, on :  off ratio 1 :  4, intensity 1.0 W/cm2, 10 minutes) and placebo in pain or function after 12 months (difference in pain scored using index from 1 to 5, no further details: + 0.1, 95% CI –0.1 to + 0.3; difference in function using the Activities of Daily Living index scored from 2–10, no further details: –0.2, 95% CI –0.5 to + 0.1). However, the RCT is likely to have been underpowered to detect a clinically important difference between groups.

Harms

None of the RCTs included in the review assessed the adverse effects of ultrasound.

Comment

In most RCTs, with the exception of the most recent (second RCT in the review), there was considerable heterogeneity of the groups, interventions, and follow up duration among the RCTs. It is not clear whether ultrasound machines were always adequately calibrated before use.

Substantive changes

No new evidence

2006; 2006: 1107.
Published online 2006 September 1.

Manipulation under anaesthesia

Summary

FUNCTIONAL IMPROVEMENT Manipulation under anaesthesia plus intra-articular hydrocortisone injection compared with intra-articular hydrocortisone injection: Manipulation under anaesthesia plus intra-articular hydrocortisone injection improves recovery rates at 3 months in people with adhesive capsulitis compared with intra-articular hydrocortisone injection ( moderate-quality evidence ). Manipulation plus intra-articular saline compared with other treatments: Manipulation under anaesthesia plus intra-articular saline may improve range of motion, pain relief, and return to normal activities at 6–8 months in people with adhesive capsulitis compared with manipulation under anaesthesia alone, or manipulation under anaesthesia plus intra-articular methylprednisolone injection ( very low-quality evidence ). ADVERSE EFFECTS Potential adverse effects of manipulation under anaesthesia include intra-articular lesions within the glenohumeral joint.

Benefits

We found two RCTs.

Manipulation plus intra-articular hydrocortisone injection versus intra-articular hydrocortisone injection alone:

The first RCT (30 people with adhesive capsulitis [frozen shoulder]) found that manipulation under anaesthesia plus intra-articular hydrocortisone injection significantly increased recovery rates compared with intra-articular hydrocortisone injection alone at 3 months (recovery, defined as no disability: 7/15 [47%] with forced manipulations v 2/15 [13%] with control; ARI 33%, 95% CI 1% to 65%). We found a second, low quality, RCT (98 people with adhesive capsulitis) comparing three interventions: manipulation under anaesthesia alone, manipulation under anaesthesia plus intra-articular injection of methylprednisolone, and manipulation under anaesthesia plus intra-articular injection of saline. All participants had physiotherapy after manipulation. It is unclear whether the trial was randomised because details of randomisation were not reported. Ten people (12 shoulders) were lost to follow up and results were not analysed by intention to treat, and the trial did not assess the significance of the difference in outcomes among groups. A good result (observer rated) was defined as improvement in active range of motion, pain relief, and return to normal activities. The RCT found that more shoulders having manipulation under anaesthesia plus intra-articular injection of saline than under other treatments had a good result at 6–8 months (88 shoulders: 25/29 [86%] shoulders with manipulation under anaesthesia plus intra-articular injection of saline v 14/28 [50%] shoulders with manipulation under anaesthesia plus intra-articular injection of methylprednisolone v 13/ 29 [45%] shoulders with manipulation under anaesthesia alone, significance not assessed).

Harms

The first RCT gave no information on adverse effects. In the second RCT, 2/88 (2%) people having manipulation under anaesthesia sustained an undisplaced fracture of the surgical neck of the humerus and 2/88 (2%) sustained an anterior dislocation of the glenohumeral joint. A further prospective study (30 people with adhesive capsulitis) assessed intra-articular lesions in people undergoing arthroscopy after manipulation under general anaesthesia. After manipulation, all participants had a haemarthrosis. In 22/30 (73%) people, localized synovitis was detected in the area of the rotator interval; in 8/30 (27%) people, disseminated synovitis was observed (a feature of adhesive capsulitis); in 11/30 (37%) people, the capsule was ruptured superiorly; in 24/30 (80%) people, the anterior capsule was ruptured up to the infraglenoid pole; and 16/30 (53%) people had a capsular lesion located posteriorly. In 18/30 (60%) people, no additional joint damage was found after manipulation. In 4/30 (13%) people, iatrogenic superior labrum anterior–posterior lesions were observed. Further injuries detected were three fresh partial tears of the subscapularis tendon, four anterior labral detachments (1 with a small osteochondral defect), and two tears of the middle glenohumeral ligament. Even though manipulation under anaesthesia is effective in terms of joint mobilisation, it can cause iatrogenic intra-articular damage.

Comment

None.

Substantive changes

Manipulation under anaesthesia One prospective study added, suggesting that manipulation under anaesthesia may increase the risk of developing intra-articular lesions within the glenohumeral joint; harms data enhanced, categorisation unchanged (likely to be beneficial).

2006; 2006: 1107.
Published online 2006 September 1.

Surgical arthroscopic decompression

Summary

FUNCTIONAL IMPROVEMENT Compared with physiotherapy: Surgical arthroscopic decompression may not improve Neer scores (pain, function, active range of movement, and anatomical or radiological examination) at 6 months and at 2.5 years in people with rotator cuff disease compared with supervised exercises ( low-quality evidence ). Surgical arthroscopic decompression plus physiotherapy compared with sham laser: Surgical arthroscopic decompression followed by physiotherapy may improve Neer scores (pain, function, active range of movement, and anatomical or radiological examination) at 6 months and at 2.5 years in people with rotator cuff disease compared with sham laser (low-quality evidence). Arthroscopic rotator cuff repair with arthroscopic subacromial decompression compared with rotator cuff repair without arthroscopic subacromial decompression: Arthroscopic rotator cuff repair with arthroscopic subacromial decompression may not reduce pain or improve functional outcomes in people with full-thickness tears limited to the supraspinatous tendon and a type 2 acromion compared with rotator cuff repair without arthroscopic subacromial decompression (low-quality evidence).

Benefits

Surgical arthroscopic decompression versus sham laser:

We found one RCT (125 people with rotator cuff disease), which compared three treatments: arthroscopic decompression by experienced surgeons plus physiotherapy; exercise supervised by experienced physiotherapist plus home exercises plus pain management; and sham laser for 6 weeks. It found that surgery significantly improved Neer score compared with sham laser at 6 months (median Neer score 87 with surgery v 66 with sham laser; P < 0.001). Long term follow up of 110 people in the RCT found that surgery significantly increased the success rate compared with sham laser at 2.5 years (success, defined as Neer score > 80: 26/38 [68%] with surgery v 7/28 [25%] with sham laser; OR 6.6, 95% CI 2.0 to 21.3).

Surgical arthroscopic decompression versus physiotherapy:

The same RCT (125 people with rotator cuff disease) found no significant difference in Neer score between arthroscopic decompression and supervised exercises at 6 months (median Neer score 87 with surgery v 86 with exercises, difference + 4.0; 95% CI –2 to + 11). Long term follow up of 110 people found no significant difference in success rates at 2.5 years (success, defined as Neer score > 80: 26/38 [68%] with surgery v 27/44 [61%] with physiotherapy; OR 1.3, 95% 0.8 to 2.2).

Arthroscopic rotator cuff repair with and without arthroscopic subacromial decompression:

One RCT (93 people with full thickness tears limited to the supraspinatus tendon and a type 2 acromion) compared arthroscopic rotator cuff repair with arthroscopic subacromial decompression versus rotator cuff repair without arthroscopic subacromial decompression. It found no significant difference in patient assessed pain or function between groups after surgery (measured by American Shoulder and Elbow Surgeons shoulder scores: mean 91.5 with subacromial decompression v 89.2 without; P = 0.392).

Harms

The RCTs gave no information on adverse effects.

Comment

None.

Substantive changes

No new evidence

2006; 2006: 1107.
Published online 2006 September 1.

Arthroscopic laser subacromial decompression

Summary

We found no direct information about arthroscopic subacromial decompression in people with shoulder pain caused by impingement syndrome.

Benefits

We found one systematic review (search date 2000) of arthroscopic subacromial decompression with holmium : YAG laser for people with shoulder pain due to impingement syndrome. It identified no RCTs.

Harms

We found no RCTs.

Comment

None.

Substantive changes

No new evidence


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