What can we expect from nonoperative treatment options for shoulder pain?

,; ,; ,

Applied Evidence

What can we expect from nonoperative treatment options for shoulder pain?

J Fam Pract. 2005 March;54(3):216-223

By

Thomas Trojian, MD

Herbert J. Stevenson, MD

Nidhi Agrawal, MD

PDF Download

References

1. Van der Windt DA, Koes BW, De Jong BA, Bouter LM. Shoulder disorders in general practice: incidence, patient characteristics, and management. Ann Rheum Dis 1995;54:959-964.

2. Blanchard TK, Bearcroft PW, Constant CR, Griffin DR, Dixon AK. Diagnostic and therapeutic impact of MRI and arthrography in the investigation of full-thickness rotator cuff tears. Eur Radiol 1999;9:638-642.

3. Neer CS. Anterior acromioplasty for chronic impingement syndrome of shoulder. J Bone Joint Surg 1972;54A:41-50.

4. Dalton SE. The conservative management of rotator cuff disorders. Br J Rheumatol 1994;33:663-667.

5. Matsen FA, Lippitt SB, Sidles JA, Harryman DT. Practical Evaluation and Management of the Shoulder. Philadelphia, Pa: W.B. Saunders; 1994.

6. Green S, Buchbinder R, Glazier R, Forbes A. Interventions for shoulder pain (Cochrane Review). In: The Cochrane Library, Issue 1, 2001. Oxdord: Update Software.

7. Van der Hiejden GJ, Van der Windt DA, Kleijnen J, et al. Steroid injections for shoulder disorders: a systematic review of randomized clinical trials. Br J Gen Pract 1996;46:309-316.

8. Van der Windt DA, Van der Heijden GJ, Scholten RJ, et al. The efficacy of non-steroidal anti-inflammatory drugs (NSAIDs) for shoulder complaints. A systematic review. J Clin Epidemiol 1995;48:691-704.

9. Van der Heijden GJ, Van der Windt DA, De Winter AF. Physiotherapy for patients with soft tissue shoulder disorders: a systematic review of randomized clinical trials. BMJ 1997;15:25-30.

10. Van der Windt DA, Van der Heijden GJ, Van den Berg GJ, et al. Ultrasound therapy for musculoskeletal disorders: a systematic review. Pain 1999;81:257-271.

11. Smith LA, Oldman AD, McQuay HJ, Moore RA. Teasing apart quality and validity in systematic reviews: an example from acupuncture trials in chronic neck and back pain. Pain 2000;86:119-132.

12. Winters JC, Sobel JS, Groenier KH, et al. Comparison of physiotherapy, manipulation, and corticosteroid injection for treating shoulder complaints in general practice: randomized, single blind study. BMJ 1997;314:1320-1325.

13. Van der Windt DA, Koes BW, Deville W, et al. Effectiveness of corticosteroid injections versus physiotherapy for treatment of painful stiff shoulder in primary care: randomized trial. BMJ 1998;317:1292-1296.

14. Mantone JK, Burkhead WZ, Noonan J. Nonoperative treatment of rotator cuff tears. Orthop Clin North Am 2000;31:295-311.

15. Lopez JM. Treatment of acute tendinitis and bursitis with fentiazac. A double blind comparison with placebo. Clin Ther 1982;5:79-84.

16. Zuinen C. Diclofenac/misprostol vs diclofenac/placebo in treating acute episodes of tendinitis/bursitis of the shoulder. Drugs 1993;45 Suppl 1:17-23.

17. Ginsberg F, Famaey JP. A double-blind comparison of slow-release and standard tablet formulations of fentiazac in the treatment of patients with tendinitis and bursitis. Curr Med Res Opin 1985;9:42-448.

18. Wober W. Comparative efficacy and safety of nimesulide and diclofenac in patients with acute shoulder, and a meta-analysis of controlled studies with nimesulide. Rheum 1999;38(Suppl 1):33-38.

19. Wober W, Rahlfs VW, Buchl N, et al. Comparative efficacy and safety of the non-steroidal anti-inflammatory drugs nimesulide and diclofenac in patients with acute subdeltoid bursitis and bicipital tendinitis. Int J Clin Pract 1998;52:169-175.

20. Valtonen E. Double acting betamethasone (celestone chronodose) in the treatment of supraspinatus tendinitis: A comparison of subacromial and gluteal single injections with placebo. J Int Men Res 1978;6:463-467.

21. Blair B, Rokito A, Cuomo F, Jarolem K, Zuckerman J. Efficacy of corticosteroids for subacromial impingement syndrome. J Bone Joint Surg Am 1996;78:1685-1689.

22. Withrington R, Girgis F, Seifert M. A placebo-controlled trial of steroid injections in the treatment of supraspinatus tendinitis. Scand J Rheumatol 1985M;14:76-78.

23. Vecchio PC, Hazleman BL, King RH. A double-blind trial comparing subacromial methylprednisolone and ligno-caine in acute rotator cuff tendinitis. Br J Rheumatol 1993;32:743-745.

24. White R, Paull D, Fleming K. Rotator cuff tendinitis: comparison of subacromial injection of a long acting corticosteroid vs oral indomethacin therapy. J Rheumatol 1986;13:608-613.

25. Adebajo A, Nash P, Hazleman B. A Prospective double blind dummy placebo controlled study comparing triamcinolone hexacetonide injection with oral diclofenac 50mg TDS in patients with rotator cuff tendinitis. J Rheumatol 1990;17:1207-1210.

26. Brox JI, Staff PH, Ljunggren AE, Revik JI. Arthroscopic Surgery compared with supervised exercises in patients with rotator cuff disease (stage II impingement syndrome). BMJ 1993;307:899-903

27. Brox JI, Gjengedal E, Uppheim G, et al. Arthroscopic surgery versus supervised exercises in patients with rotator cuff disease (stage II impingement syndrome): a prosprective, randomized, controlled study in 125 patients with a 2 1/2 year follow up. J Shoulder Elbow Surg 1999;8:102-111.

28. Bokor DJ, Hawkins RJ, Huckell GH, Angelo RL, Schickendantz MS. Results of nonoperative management of full-thickness tears of the rotator cuff. Clin Orthop 1993;294:103-110.

29. Itoi E, Tabata S. Conservative treatment of rotator cuff tears. Clin Orthop 1992;275:165-173.

30. Hawkins RH, Dunlop R. Nonoperative treatment of rotator cuff tears. Clin Orthop 1995;321:178-188.

31. Goldberg BA, Nowinski RJ, Matsen FA. Outcome of non-operative management of full thickness rotator cuff tears. Clin Orthop 2001;382:99-107.

32. Weiss JJ. Intra-articular steroids in the treatment of rota-tor cuff tear: reappraisal by arthrography. Arch Phys Med Rehabil 1981;62:555-557.

33. De Jong BA, Dahmen R, Hogeweg JA, Marti RK. Intra-articular triamcinolone acetonide injection in patients with capsulitis of the shoulder: a comparative study of two dose regimens. Clin Rehab 1998;12:211-215.

34. Bulgen DY, Binder AI, Hazleman BL, Dutton J, Roberts S. Frozen shoulder: prospective clonical study with an evaluation of three treatment regimens. Ann Rheum Dis 1984;43:353-360.

35. Thumb N, Kolarz G, Scherak O, Mayrhofer F. The efficacy and safety of Fentiazac and Diclofenac sodium in peri-arthritis of the shoulder: a multi-center, double-blind comparison. J Int Med Res 1987;15:327-334.

36. Rhind V, Downie WW, Bird HA, Wright V, Engler C. Naproxen and indomethacin in periarthritis of the shoulder. Rheumatol Rehabil 1982;21:51-53.

37. Lee PN, Lee M, Haq AM, Longton EB, Wright V. Periarthritis of the shoulder. Ann Rheum Dis 1974;33:116-119.

38. Hazleman BL. The painful stiff shoulder. Rheumatol Rehabil 1972;11:413-421.

39. Croft P, Pope D, Silman A. The clinical course of shoulder pain: prospective cohort study in primary care. BMJ 1996;313:601-602.

40. Van der Windt DA, Koes BW, Boeke AJ, Deville W, De Jong BA, Bouter LM. Shoulder disorders in general practice: prognostic indicators of outcome. Br J Gen Pract 1996;46:519-523.

41. Iannotti JP, Zlatkin MB, Esterhai JL, Kressel HY, Dalinka MK, Spindler KP. Magnetic resonance imaging of the shoulder. Sensitivity, specificity, and predictive value. J Bone Joint Surg 1991;73:17-29.

42. Burk DL, Karasick D, Kurtz AB, et al. Rotator cuff tears: prospective comparison of MR imaging with arthrography, sonography, and surgery. Am J Roentgenol 1989;153:87-92.

43. Torstensen ET, Hollinshead RM. Comparison of magnetic resonance imaging and arthroscopy in the evaluation of shoulder pathology. J Shoulder Elbow Surg 1999;8:42-45.

44. Yeu K, Jiang CC, Shih TT. Correlation between MRI and operative findings of the rotator cuff tear. J Formos Med Assoc 1994;93:134-139.

45. Green MR, Christensen KP. Magnetic resonance imaging of the glenoid labrum in anterior shoulder instability. Am J Sports Med 1994;22:493-498.

46. Gusmer PB, Potter HG, Schaltz JA, et al. Labral injuries: accuracy of detection with en-enhanced MR imaging of the shoulder. Radiology 1996;200:519-524.

47. Farin PU, Kaukanen E, Jaroma H, Vaatainen U, Miettinen H, Soimakallio S. Site and size of rotator cuff tear. Findings at ultrasound, double contrast arthrography, and computed tomography arthrography with surgical correlation. Invest Radiol 1996;31:387-394.

48. Teefey SA, Hasan SA, Middleton WD, Patel M, Wright RW, Yamaguchi K. Ultrasonography of the rotator cuff. A comparison of ultrasonographic and arthroscopic findings in one hundred consecutive cases. J Bone Joint Surg Am 2000;82:498-504.

49. Van Moppes FI, Veldkam O, Roorda J. Role of shoulder ultrasonography in the evaluation of the painful shoulder. Eur J Radiol 1995;19:142-146.

Practice recommendations

First-line treatment for shoulder pain and stage 1 impingement may include nonsteroidal anti-inflammatory drugs (NSAIDs) (B) or corticosteroid injection (A).
Stage II or III Impingement (rotator cuff tears) are best treated initially with physical therapy (supervised or home exercise program) or corticosteroid injection.
Steroid injections added to NSAID treatment probably confer no extra benefit.
High pain levels during the day and associated neck pain may predict a longer recovery period.

Most shoulder pain responds best to NSAIDs or subacromial corticosteroid injections followed by a home exercise program or formal physical therapy exercises. Accumulating evidence is making it clearer what works and what doesn’t for specific diagnoses.

Time to healing varies greatly among persons with shoulder pain, and specific prognostic indicators may help you and your patients know what to expect.

Quick diagnostic review

Consider the patient’s age, history of trauma, details of injury, and previous shoulder problems. Observe the patient’s general movements, assess range of motion, and use provocative testing to form a differential diagnosis ( Figure 1 ).

If the diagnosis is unclear, arrange for imaging studies ( Table 1 ). A more thorough review for diagnosing shoulder pain may be found in the article “Approach to the patient with shoulder pain” (J Fam Pract 2002; 7:605–611). The conditions causing shoulder pain (in order of frequency, as seen by primary care physicians) are subacromial impingement syndrome (SIS), adhesive capsulitis, acute bursitis, calcific tendinitis, glenohumeral arthrosis, biceps tendinitis, and labral tear.^1,2

TABLE 1
Value of imaging tests for shoulder injuries

Test	LOE	Sn	Sp	LR+	LR−	PV+	PV−
MRI
Rotator cuff tears
Partial⁴¹	2b	82	85	5.5	0.21	82	85
Complete⁴¹	1a	81	78	3.7	0.24	—	—
Overall^42-44	2b	89–96	49–100	1.9–>25	0.08	58	94
Impingement ⁴²	2b	93	87	7.2	0.08	93	87
Labral tears* ^45,46	1b	75–89	97–100	>25	0.11–0.25	100	41
Plain arthrogram
Rotator cuff tears
Partial⁴⁷	1b	70	—	—	—	—	—
Complete⁴¹	1b	50	96	13	0.52	—	—
CT arthrogram
Rotator cuff tears
Partial⁴⁷	1b	70	—	—	—	—	—
Complete⁴⁷	1b	95	—	—	—	—	—
Overall⁴⁷	1b	86	98	>25	0.14	96	93
Ultrasound
Rotator cuff tears
Partial⁴⁷	1b	80	—	—	—	—	—
Complete^47,4848	1b	90–100	85	6.7	>25	—	—
Overall⁴⁷	1b	86	91–98	9.6–>25	0.14–0.15	96	73–93
*MRI arthrography.
LOE, level of evidence (SORT); Sn, sensitivity; Sp, specificity; LR, likelihood ratio; PV, predictive value; MRI, magnetic resonance imaging; CT, computed tomography.

FIGURE 1
Evaluating shoulder pain for possible rotator cuff tear

Subacromial impingement syndrome

This condition was first described by Neer, who estimated it leads to 95% of rotator cuff tears.³

Impingement occurs from repetitive overhead activities, acute trauma, or instability of the glenohumeral joint (subtle or overt). Current theory holds that degeneration of the rotator cuff tendons or inflammation of the subacromial bursa—caused by irritation against the coracoacromial arch—can progress to degeneration and a complete rotator cuff tear. So-called rotator cuff tendinitis is better described as a tendinopathy with mucoid degeneration of the tendon. SIS stage I involves edema and hemorrhage, as would be seen with rotator cuff tendinopathy or bursitis.

Progressive feedback loop of subacromial impingement syndrome. Acute bursitis involves the subacromial bursa and typically is secondary to subacromial impingement. As underlying tendinopathy, instability, or heterotrophic bone irritates the bursa, it will become inflamed and irritated. Inflammation exacerbates the impingement and that in turn causes worsening of the bursitis.

Stage II and III impingement syndrome. SIS stage II is a progression to fibrosis and partial tear of the rotator cuff. Stage III is a full-thickness tear of the rotator cuff. These stages of SIS are seen predominantly in patients over the age of 40 years, and they become more common with increasing age. The tear—partial or complete— usually occurs in the supraspinatus tendon. Tears of other rotator cuff muscles are less common.

Magnetic resonance imaging (MRI), with or without arthrography, is used in clinical practice and in research to diagnose rotator cuff tears. Growing evidence indicates that ultrasound is a less expensive and equally effective way to diagnose stage II or III impingement. In the United States, however, the option of ultrasound is limited by scarce availability and inadequate operator skill.

The subacromial injection test is useful in clinical practice. Local anesthetic is injected into the subacromial space. Persisting loss of strength despite pain relief is a positive sign of impairment of the rotator cuff.

MRI or ultrasound must be done in conjunction with history taking and physical examination. As the age of a person increases, the amount of asymptomatic rotator cuff tendon injury will also increase. The incidence of rotator cuff tears has been found to be between 50% to 60% in cadavers of deceased elderly. Thirty percent were found to be stage III impingement; 20% to 30% were partial stage II impingement.⁴

Adhesive capsulitis

Also known as frozen shoulder, adhesive capsulitis may begin with any inflammatory condition, but it is most commonly idiopathic. It characteristically progresses through 3 stages.

The hallmark of adhesive capsulitis is a progressive lack of range of motion with both passive and active movement.

The first stage involves progressive pain and decreased range of motion as the capsule scars.