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.
Physiotherapy seems to be of similar efficacy to intra-articular or sub-acromial corticosteroid injections or surgical arthroscopic decompression over 6-12 months.
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
| Important outcomes | Symptom severity, functional improvement, mobility, adverse effects | ||||||||
| Number of studies (participants) | Outcome | Comparison | Type of evidence | Quality | Consistency | Directness | Effect size | GRADE | Comment |
| What are the effects of oral drug treatment? | |||||||||
| 2 (82) | Symptom severity | Oral corticosteroids v placebo | 4 | –2 | –1 | –1 | 0 | Very low | Quality points deducted for sparse data and incomplete reporting of results. Consistency point deducted for conflicting results. Directness point deducted for no inter-group comparisons |
| 1 (46) | Functional improvement | Oral corticosteroids v placebo | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for sparse data |
| 1 (40) | Symptom severity | Oral corticosteroids plus home exercises v home exercises alone | 4 | –2 | 0 | –1 | 0 | Very low | Quality points deducted for sparse data and incomplete reporting of results. Directness point deducted for inclusion of other drug interventions |
| 4 (411) | Symptom severity | Oral NSAIDs v placebo | 4 | –2 | –1 | –3 | 0 | Very low | Quality points deducted for incomplete reporting of results and subjective assessment of outcome. Consistency point deducted for conflicting results. Directness points deducted for diverse comparators, variation in outcome measures and follow-up times, and uncertainty about definition of shoulder pain |
| What are the effects of topical drug treatment? | |||||||||
| 1 (24) | Symptom severity | Phonophoresis v placebo/sham phonophoresis | 4 | –2 | 0 | –1 | 0 | Very low | Quality points deducted for sparse data and incomplete reporting of results. Directness point deducted for inclusion of people without shoulder pain |
| 1 (20) | Symptom severity | Transdermal glyceryl trinitrate v placebo | 4 | –2 | 0 | –1 | 0 | Very low | Quality points deducted for sparse data and incomplete reporting of results. Directness point deducted for no direct comparison between groups |
| 1 (20) | Functional improvement | Transdermal glyceryl trinitrate v placebo | 4 | –2 | 0 | –1 | 0 | Very low | Quality points deducted for sparse data and incomplete reporting of results. Directness point deducted for no direct comparison between groups |
| What are the effects of local injections? | |||||||||
| 3 (167) | Symptom severity | Suprascapular nerve block v placebo | 4 | –3 | –1 | –2 | 0 | Very low | Quality points deducted for sparse data, incomplete reporting of results, no intention-to-treat analysis, and poor follow-up. Consistency point deducted for conflicting results. Directness points deducted for inclusion of people with degenerative disease, and uncertainty about benefit of treatment in people with non-arthritic pain |
| 2 (142) | Functional improvement | Suprascapular nerve block v placebo | 4 | –3 | –1 | –2 | 0 | Very low | Quality points deducted for sparse data, incomplete reporting of results, no intention-to-treat analysis, and poor follow-up. Consistency point deducted for conflicting results. Directness points deducted for inclusion of people with degenerative disease, and uncertainty about benefit of treatment in people with non-arthritic pain |
| 1 (93) | Symptom severity | Intra-articular corticosteroid injection v placebo | 4 | –3 | –1 | 0 | 0 | Very low | Quality points deducted for sparse data, incomplete reporting of results, and uncertainty about quality of methods used. Consistency point deducted for different results at different endpoints |
| 1 (93) | Functional improvement | Intra-articular corticosteroid injection v placebo | 4 | –3 | –1 | 0 | 0 | Very low | Quality points deducted for sparse data, incomplete reporting of results, and uncertainty about quality of methods used. Consistency point deducted for different results at different endpoints |
| 2 (108) | Symptom severity | Intra-articular corticosteroid injection plus lidocaine v lidocaine/placebo | 4 | –3 | 0 | 0 | 0 | Very low | Quality points deducted for sparse data, incomplete reporting of results, and uncertainty about quality of methods used |
| 1 (48) | Functional improvement | Intra-articular corticosteroid injection plus lidocaine v lidocaine | 4 | –3 | 0 | 0 | 0 | Very low | Quality points deducted for sparse data, incomplete reporting of results, and uncertainty about quality of methods used |
| 2 (201) | Symptom severity | Intra-articular corticosteroid injection v physiotherapy | 4 | –2 | –1 | 0 | 0 | Very low | Quality points deducted for incomplete reporting of results, and uncertainty about quality of methods used. Consistency point deducted for different results at different endpoints |
| 2 (201) | Functional improvement | Intra-articular corticosteroid injection v physiotherapy | 4 | –2 | –1 | 0 | 0 | Very low | Quality points deducted for incomplete reporting of results, and uncertainty about quality of methods used. Consistency point deducted for different results at different endpoints |
| 1 (57) | Symptom severity | Higher doses v lower doses of intra-articular corticosteroid injection | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 1 (57) | Functional improvement | Higher doses v lower doses of intra-articular corticosteroid injection | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 1 (18) | Symptom severity | Intra-articular guanethidine v placebo | 4 | –2 | 0 | –1 | 0 | Very low | Quality points deducted for sparse data and incomplete reporting of results. Directness point deducted for uncertainty about benefit of treatment in people with non-arthritic shoulder pain |
| 1 (18) | Functional improvement | Intra-articular guanethidine v placebo | 4 | –2 | 0 | –1 | 0 | Very low | Quality points deducted for sparse data and incomplete reporting of results. Directness point deducted for uncertainty about benefit of treatment in people with non-arthritic shoulder pain |
| 4 (186) | Symptom severity | Subacromial corticosteroid injections plus lidocaine v lidocaine | 4 | –3 | –1 | –1 | 0 | Very low | Quality points deducted for sparse data, incomplete reporting of results, uncertainties about intention-to-treat analysis, and follow-up timings. Consistency point deducted for conflicting results. Directness point deducted for uncertainty about accuracy of technique |
| 4 (186) | Functional improvement | Subacromial corticosteroid injections plus lidocaine v lidocaine | 4 | –3 | –1 | –1 | 0 | Very low | Quality points deducted for sparse data, incomplete reporting of results, uncertainties about intention-to-treat analysis, and follow-up timings. Consistency point deducted for conflicting results. Directness point deducted for uncertainty about accuracy of technique |
| 1 (98) | Symptom severity | Subacromial corticosteroid injections plus bupivacine v bupivacaine | 4 | –2 | 0 | –1 | 0 | Very low | Quality points deducted for sparse data and incomplete reporting of results. Directness point deducted for uncertainty about accuracy of technique |
| 1 (98) | Functional improvement | Subacromial corticosteroid injections plus bupivacine v bupivacaine | 4 | –2 | 0 | –2 | 0 | Very low | Quality points deducted for sparse data and incomplete reporting of results. Directness points deducted for uncertainty about accuracy of technique and measurement of outcome |
| 2 (142) | Symptom severity | Subacromial corticosteroid injections plus intra-articular corticosteroid injections v placebo | 4 | –2 | –1 | –1 | 0 | Very low | Quality points deducted for sparse data and incomplete reporting of results. Consistency point deducted for conflicting results. Directness point deducted for uncertainty about accuracy of technique and measurement of outcome |
| 2 (142) | Functional improvement | Subacromial corticosteroid injections plus intra-articular corticosteroid injections v placebo | 4 | –2 | –1 | –2 | 0 | Very low | Quality points deducted for sparse data and incomplete reporting of results. Consistency point deducted for conflicting results. Directness points deducted for uncertainty about accuracy of technique and measurement of outcome |
| 1 (207) | Functional improvement | Subacromial corticosteroid injection plus lidocaine v physiotherapy | 4 | 0 | 0 | –2 | 0 | Low | Directness points deducted for uncertainty about technique and measurement of outcome |
| What are the effects of non-drug treatment? | |||||||||
| 3 (315) | Symptom severity | ESWT v placebo | 4 | –2 | 0 | 0 | –1 | Very low | Quality points deducted for poor follow-up and no intention-to-treat analysis. Directness point deducted for no direct comparison between groups |
| 1 (91) | Symptom severity | Two sessions v one session | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for sparse data |
| 3 (315) | Functional improvement | ESWT v placebo | 4 | –2 | 0 | 0 | –1 | Very low | Quality points deducted for poor follow-up and no intention-to-treat analysis. Directness point deducted for no direct comparison between groups |
| 2 (112) | Symptom severity | ESWT v sham treatment (non-calcific rotator cuff tendinopathy) | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for sparse data |
| 1 (38 | Functional improvement | ESWT v sham treatment (non-calcific rotator cuff tendinopathy) | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for sparse data |
| 3 (79) | Symptom severity | Laser treatment v placebo | 4 | –2 | –1 | 0 | 0 | Very low | Quality points deducted for sparse data and lack of standardisation. Consistency point deducted for conflicting results |
| 1 (66) | Symptom severity | Physiotherapy plus home exercises v no treatment | 4 | –2 | 0 | –1 | 0 | Very low | Quality points deducted for sparse data and lack of standardisation. Directness point deducted for diverse disorders |
| 1 (125) | Symptom severity | Physiotherapy v sham laser | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and lack of standardisation |
| 1 (42) | Symptom severity | Maitland mobilisation v no treatment | 4 | –3 | 0 | 0 | 0 | Very low | Quality points deducted for sparse data, incomplete reporting of results, and lack of standardisation |
| 1 (42) | Functional improvement | Maitland mobilisaton v no treatment/other treatment | 4 | –3 | 0 | 0 | 0 | Very low | Quality points deducted for sparse data, incomplete reporting of results, and lack of standardisation |
| 2 (205) | Symptom severity | Electrical stimulation v sham electrical stimulation | 4 | –2 | –2 | 0 | 0 | Very low | Quality points deducted for incomplete reporting of results, and lack of standardisation in methods. Consistency point deducted for different results for different outcomes |
| 1 (70) | Symptom severity | Multidisciplinary biopsychosocial rehabilitation v usual treatment | 4 | –3 | 0 | –2 | 0 | Very low | Quality points deducted for sparse data, incomplete reporting of results, methodological flaws, no intention-to-treat analysis, and uncertainty about blinding. Directness points deducted for co-interventions and baseline differences between groups |
| 5 (373) | Symptom severity | Ultrasound v placebo/no treatment | 4 | –3 | –1 | –3 | 0 | Very low | Quality points deducted for incomplete reporting of results and uncertainty about methodology (calibration). Consistency point deducted for conflicting results. Directness point deducted for heterogeneity between groups, interventions, and follow-up durations |
| 5 (373) | Functional improvement | Ultrasound v placebo/no treatment | 4 | –3 | –1 | –3 | 0 | Very low | Quality points deducted for incomplete reporting of results, and uncertainty about methodology (calibration). Consistency point deducted for conflicting results. Directness point deducted for heterogeneity between groups, interventions, and follow-up durations |
| What are the effects of surgical treatment? | |||||||||
| 1 (30) | Functional improvement | Manipulation plus intra-articular hydrocortisone injection vintra-articular hydrocortisone injection | 4 | –1 | 0 | 0 | 0 | Moderate | Quality point deducted for sparse data |
| 1 (86) | Functional improvement | Manipulation plus intra-articular saline v other treatments | 4 | –3 | 0 | –1 | 0 | Very low | Quality points deducted for sparse data, no intention-to-treat analysis, incomplete reporting of results, and uncertainty about randomisation. Directness point deducted for unclear measurement of outcomes |
| 1 (125) | Symptom severity | Surgical arthroscopic decompression plus physiotherapy v sham laser | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 1 (125) | Symptom severity | Surgical arthroscopic decompression v physiotherapy | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 1 (93) | Functional improvment | Arthroscopic rotator cuff repair with arthroscopic subacromial decompression v rotator cuff repair without arthroscopic subacromial decompression | 4 | –2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
Type of evidence: 4 = RCT; 2 = Observational; 1 = Non-analytical/expert opinion. ESWT, Extracorporeal shock wave therapyConsistency: similarity of results across studies Directness: generalisability of population or outcomes Effect size: based on relative risk or odds ratio
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.
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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