Table 3. Summary of selected systematic reviews of the conservative management of shoulder disorders.

Treatment modality	Case definition	Outcome measures	Summary of evidence	References
Physiotherapy interventions	Shoulder pain	Pain Stiffness Disability	Cochrane review: There is no evidence of the effect of ultrasound in shoulder pain (mixed diagnosis)	[76]
Physiotherapy interventions	Rotator cuff disease	Pain Stiffness Disability	Cochrane review: Exercise was demonstrated to be effective in terms of short term recovery (RR 7.74 (1.97, 30.32), and longer term benefit with respect to function (RR 2.45 (1.24, 4.86). Combining mobilisation with exercise resulted in additional benefit when compared to exercise alone. Laser therapy was not more effective than placebo for supraspinatus tendinitis (RR 2, 95%CI 0.98 to 4.09). There is no evidence of the effect of ultrasound alone.	[76]
Physiotherapy interventions	Adhesive capsulitis	Pain Stiffness Disability	Cochrane review: Laser therapy was demonstrated to be more effective than placebo (RR 8, 95%CI 2.11 to 30.34). There is no evidence of the effect of either ultrasound or physiotherapy alone.	[76]
Physiotherapy interventions	Calcific tendinitis	Pain Stiffness Disability	Cochrane review: Both ultrasound and pulsed electromagnetic field therapy resulted in improvement compared to placebo for pain (RR 1.81 (1.26, 2.60) and RR 19 (1.16, 12.43) respectively	[76]
Glucocorticoid injections	Rotator cuff disease	Pain Stiffness Disability	Cochrane review: Subacromial steroid injection was demonstrated to have a small benefit over placebo in some trials however no benefit of subacromial steroid injection over NSAID was demonstrated based upon the pooled results of three trials.	[77]
	Adhesive capsulitis	Pain Stiffness Disability	Cochrane review: For adhesive capsulitis, two trials suggested a possible early benefit of intra-articular steroid injection over placebo. One trial suggested short- term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term (success at seven weeks RR=1.66 (1.21, 2.28) Data from two RCTs showed that there may be benefit from adding a single intra-articular steroid injection to home exercise in patients with < 6 months' duration. The same two trials showed that there may be benefit from adding physiotherapy (including mobilisation) to a single steroid injection. steroid combined with physiotherapy was the only treatment showing a statistically and clinically significant beneficial treatment effect compared with placebo for short-term pain (standardised mean difference -1.58, 95% credible interval -2.96 to - 0.42).	[77] [78]
Image-guided vs blind glucocorticoid injections	Rotator cuff disease Adhesive capsulitis	Pain Function Range of motion Proportion of participants with overall improvement	Cochrane review: Based upon moderate evidence from five trials, our review was unable to establish any advantage in terms of pain, function, shoulder range of motion or safety, of ultrasound-guided glucocorticoid injection for shoulder disorders over either landmark-guided or intramuscular injection.	[79]
Oral glucocorticoids	Adhesive capsulitis	Pain Range of motion Function	Cochrane review: ‘Silver’ evidence that oral steroids provide significant short-term benefits in pain, range of movement of the shoulder and function but the effect may not be maintained beyond six weeks.	[80]
Arthrographic distension	Adhesive capsulitis	Pain Range of motion Function	Cochrane review: There is “silver” level evidence that arthrographic distension with saline and steroid provides short-term benefits (up to 12 weeks) in pain, range of movement and function. It is uncertain whether this is better than alternative interventions.	[81])
Acupuncture	Rotator cuff disease Adhesive capsulitis Full thickness rotator cuff tear Shoulder pain (mixed diagnoses)	Pain Range of motion Function	Cochrane review: Due to a small number of clinical and methodologically diverse trials, little can be concluded from this review. There is little evidence to support or refute the use of acupuncture for shoulder pain although there may be short-term benefit with respect to pain and function. There is a need for further well designed clinical trials.	[82]
Electrotherapy	Adhesive capsulitis	Pain Function Global treatment success	Cochrane review: No comparison with placebo. Based upon low quality evidence from one trial, low-level laser therapy for six days may be more effective than placebo on global treatment success at six days. Based upon moderate quality evidence from one trial, laser therapy plus exercise for eight weeks may be more effective than exercise alone in terms of pain up to four weeks, and function up to four months.	[83]
Manual therapy and exercise	Adhesive capsulitis	Pain Function Patient-reported treatment success	Cochrane review: No trials of exercise vs. placebo A combination of manual therapy and exercise may not be as effective as glucocorticoid injection in the short-term (6 weeks). It is unclear whether a combination of manual therapy, exercise and electrotherapy is an effective adjunct to glucocorticoid injection or oral NSAID. Following arthrographic joint distension with glucocorticoid and saline, manual therapy and exercise may confer effects similar to those of sham ultrasound in terms of overall pain, function and quality of life, but may provide greater patient-reported treatment success and active range of motion	[84]
Multidisciplinary bio-psychosocial rehabilitation	Working-aged adults with neck and shoulder pain	Pain	Cochrane review: Insufficient evidence of efficacy.	[85]
Conservative interventions	Work-related complaints of the arm, neck or shoulder in adults	Pain Recovery Disability Sick leave	Cochrane review: Very low-quality evidence that pain, recovery, disability and sick leave are similar after exercises when compared with no treatment, with minor intervention controls or with exercises provided as additional treatment to people with work-related complaints of the arm, neck or shoulder. Low-quality evidence also showed that ergonomic interventions did not decrease pain at short-term follow-up but did decrease pain at long-term follow-up. No evidence of an effect on other outcomes. For behavioural and other interventions, there was no evidence of a consistent effect on any of the outcomes.	[86]