Shoulder pain

Overview

Abstract | Cite as | Substantive changes

Abstract

INTRODUCTION: 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). RESULTS: 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. CONCLUSIONS: 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.

Cite as

Murphy RJ and Carr AJ. Shoulder pain. Clinical Evidence 2010; 07:.

Top

Substantive changes

Corticosteroids (oral) One systematic review added (search date 2005),[29] which found two small RCTs comparing oral corticosteroids versus placebo, which were already reported in this Clinical Evidence review. No new data added. The review also found three small RCTs comparing oral corticosteroids plus home exercises versus home exercises alone (40 people), oral corticosteroids plus manipulation under anaesthesia plus intra-articular injection of corticosteroid versus manipulation under anaesthesia plus intra-articular injection of corticosteroid manipulation alone (30 people), and oral corticosteroid plus physiotherapy versus intra-articular injection of corticosteroid plus physiotherapy (28 people).[29] The first RCT had been previously reported in this Clinical Evidence review; the second RCT found no consistent differences between groups; the third RCT only reported outcomes up to 3 weeks. Categorisation unchanged (Unknown effectiveness).

Intra-articular corticosteroid injections One RCT (53 people) added comparing intra-articular corticosteroid injections plus physiotherapy versus manipulation under anaesthesia plus physiotherapy in people with glenohumeral joint disease.[48]The RCT found no significant differences between groups in pain or function at 16 weeks. One systematic review (search date 2005)[29] added, which found one small RCT (28 people)[34]comparing intra-articular injection of corticosteroids plus physiotherapy versus oral corticosteroids plus physiotherapy in people with glenohumeral joint disease, which only reported outcomes at 3 weeks. Categorisation unchanged (Unknown effectiveness).

Subacromial corticosteroid injections One RCT (56 people) added comparing subacromial injection of methylprednisolone plus lidocaine versus injection of lidocaine alone.[59] The RCT found similar results to four previously reported RCTs. One systematic review added (search date 2006),[54] which identified one RCT previously reported in this Clinical Evidence review comparing subacromial methylprednisolone plus lidocaine versus physiotherapy. No new data added. One further RCT added to comments as background data.[61]Categorisation unchanged (Unknown effectiveness).

Autologous whole blood injections New option. We found no RCTs. Autologous whole blood injections categorised as Unknown effectiveness.

Platelet-rich plasma injections New option. We found one small RCT (40 people) comparing the effects of open subacromial decompression plus platelet-rich plasma injection versus open subacromial decompression without platelet-rich plasma injection in people with rotator cuff disease. [62]The small RCT found evidence of benefit in terms of pain and function at between 2 and 12 weeks, but not in shoulder instability. We found no further RCTs in people with non-specific shoulder pain, acromioclavicular joint disease, or glenohumeral joint disease. Plasma-rich platelet injections categorised as Unknown effectiveness.

Extracorporeal shock wave therapy One small RCT (46 people) comparing extracorporeal shock wave therapy (ESWT) versus sham ESWT in people with calcific tendonitis. [66]The RCT found similar results to three previously reported larger RCTs of benefits with regard to pain and function with ESWT. Categorisation unchanged (Likely to be beneficial).

Laser treatment We found one RCT (63 people) comparing the effects of low-level laser treatment versus sham laser treatment in people with frozen shoulder. The RCT found evidence of benefit in terms of pain and composite outcomes of disability up to 16 weeks, but no difference in range of shoulder movement.[69] We found one RCT (70 people) comparing high-intensity laser treatment versus ultrasound treatment.[76] The RCT found some evidence of benefit with laser in terms of pain at 2 weeks, but no difference between groups in composite scores of pain and function. Categorisation unchanged (Likely to be beneficial).

Ultrasound We found one RCT comparing ultrasound treatment versus high-intensity laser treatment in people with rotator cuff disease.[76]The RCT found some evidence of benefit with laser in terms of pain at 2 weeks, but no difference between groups in composite scores of pain and function. We found one RCT (49 people) comparing ultrasound treatment plus physiotherapy versus sham ultrasound treatment plus physiotherapy, in addition to heat treatment and physical exercises, in people with glenohumeral joint disease.[86]The RCT found no significant difference between groups in terms of pain or shoulder disability scores. We found one small RCT (38 people) comparing ultrasound plus physiotherapy versus sham ultrasound treatment plus physiotherapy in people with rotator cuff disease.[90]The RCT found no significant difference between groups in pain, disability scores, or range of movement at 21 days. One systematic review (search date 2003) added, which included one RCT (60 people) comparing ultrasound versus acupuncture in people with rotator cuff disease.[91]The RCT found no significant difference between groups in pain, range of abduction, or success rate at 4 weeks. We found one RCT (85 people) comparing ultrasound treatment plus physiotherapy versus acupuncture plus physiotherapy in people with subacromial impingement.[92]The RCT found no significant difference between groups in terms of composite shoulder scores. Categorisation unchanged (Unknown effectiveness) as all RCTs added had weak methods.

Acupuncture New option. One systematic review (search date 2003) added, which included one RCT (60 people) comparing the effects of acupuncture versus ultrasound in people with rotator cuff disease.[91] The RCT found no significant difference between groups in pain, range of abduction, or success rate at 4 weeks. One RCT (85 people) added comparing acupuncture plus physiotherapy versus ultrasound treatment plus physiotherapy in people with subacromial impingement.[92]The RCT found no significant difference between groups in terms of composite shoulder scores. One systematic review (search date 2003) added,[91] which included one RCT (42 people)[93] and one subsequent RCT (130 people),[94] which compared the effects of acupuncture versus placebo in people with non-specific shoulder pain. The larger RCT found some evidence of benefit with acupuncture in terms of improvement in pain and function, while the other RCT found no significant difference between groups with regard to overall improvement, but this RCT was of low methodological quality. The systematic review also included one small RCT (24 people) comparing the effects of acupuncture versus placebo in people with rotator cuff disease. The RCT found no evidence of benefit with acupuncture in terms of pain or function at 4 weeks, but may have been too small to detect clinically important differences between groups. Acupuncture categorised as Unknown effectiveness.

Manipulation under anaesthesia Existing evidence re-evaluated. Categorisation changed from Likely to be beneficial to Unknown effectiveness.

Shoulder arthroplasty New option. We found no RCTs. Categorised as Unknown effectiveness.

Rotator cuff repair New option. We found no RCTs. Categorised as Unknown effectiveness.

Excision of distal clavicle New option. We found no RCTs. Categorised as Unknown effectiveness.

Latest citations

Early Versus Delayed Passive Range of Motion Exercise for Arthroscopic Rotator Cuff Repair: A Meta-analysis of Randomized Controlled Trials. ( 27 October 2014 )

Platelet-Rich Plasma Injections in the Treatment of Chronic Rotator Cuff Tendinopathy: A Randomized Controlled Trial With 1-Year Follow-up. ( 20 October 2014 )