Shoulder pain is a common problem with an estimated prevalence of 4% to 26%. About 1% of adults aged over 45 years consult their GP with a new presentation of shoulder pain every year in the UK. The aetiology of shoulder pain is diverse and includes pathology originating from the neck, glenohumeral joint, acromioclavicular joint, rotator cuff, and other soft tissues around the shoulder girdle. The most common source of shoulder pain is the rotator cuff, accounting for over two-thirds of cases.
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 August 2009 (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).
We found 71 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
In this systematic review we present information relating to the effectiveness and safety of the following interventions: acupuncture, arthroscopic subacromial decompression, autologous whole blood injection, corticosteroids (oral, subacromial injection, or intra-articular injection), electrical stimulation, excision of distal clavicle, extracorporeal shock wave therapy, ice, laser treatment, manipulation under anaesthesia, suprascapular nerve block, non-steroidal anti-inflammatory drugs (oral, topical or intra-articular injection), opioid analgesics, paracetamol, physiotherapy (manual treatment, exercises), platelet-rich plasma injection, rotator cuff repair, shoulder arthroplasty, and ultrasound.
Shoulder pain encompasses a diverse array of pathologies and can affect as many as one quarter of the population depending on age and risk factors.
Shoulder pain may be due to problems with the neck, glenohumeral joint, acromioclavicular joint, rotator cuff, or other soft tissues around the shoulder.
Rotator cuff problems are the most common source of shoulder pain, accounting for more than two-thirds of cases.
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.
Frozen shoulder (adhesive capsulitis) 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 permit a return to normal functional use of the shoulder and encourage this with manual exercises. In people with acute post-traumatic tear, an early surgical option is warranted.
We don't know whether topical NSAIDs, oral corticosteroids, oral paracetamol, or opioid analgesics improve shoulder pain, although oral NSAIDs may be effective in the short term in people with acute tendonitis/subacromial bursitis. If pain control fails, the diagnosis should be reviewed and other interventions considered.
Physiotherapy may improve pain and function in people with mixed shoulder disorders compared with placebo.
Intra-articular corticosteroid injections may reduce pain in the short term compared with physiotherapy and placebo for people with frozen shoulder, but their benefit in the long term and when compared with local anaesthetic is unclear.
Platelet-rich plasma injections may improve the speed of recovery in terms of pain and function in people having open subacromial decompression for rotator cuff impingement, but further evidence is needed.
Acupuncture may not improve pain or function in people with rotator cuff impingement compared with placebo or ultrasound.
Extracorporeal shock wave therapy may improve pain in calcific tendonitis.
We found some evidence that suprascapular nerve block, laser treatment, and arthroscopic subacromial decompression may be effective in some people with shoulder pain.
We don't know whether autologous blood injections, intra-articular NSAID injections, subacromial corticosteroid injections, electrical stimulation, ice, ultrasound, rotator cuff repair, manipulation under anaesthesia, or shoulder arthroplasty are effective as we found insufficient evidence on their effects.