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

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Applied Evidence

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

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

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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.

The second stage involves maturation of capsule scaring, resulting in decreased pain and increased restriction of movement.

The third stage is resolution of the condition, leading to a gradual increase in range of motion.

Full range of motion may or may not return, and the time to resolution is typically 1 to 2 years. Adhesive capsulitis is most common in older persons, especially women in the fourth and fifth decades.⁵

Comparing nonoperative treatments

Nonoperative treatment modalities include protection, relative rest, and ice (PRI); anti-inflammatory medications; physical therapy (supervised or home exercise program); acupuncture; and steroid injection.

Operative treatments, depending on the particular disorder, include rotator cuff repair, subacromial decompression, capsular tightening, or manipulation under anesthesia.

The efficacy of nonoperative treatments for shoulder pain is not well known. Studies of treatment modalities have been numerous but generally of poor quality due to a lack of uniformity in how shoulder disorders are defined and in the variability of outcome measures used. Several recent systematic reviews have tried to identify which interventions are efficacious ( Table 2 ).^6-11

Overall, NSAIDs and subacromial steroid injections are effective in the short-term treatment of shoulder pain.^26-28 However, only nonselective NSAIDs have been studied. Evidence is insufficient to recommend use of cyclooxygenase-2 (COX-2) medications for shoulder pain.

Steroid injections may not confer extra benefit when added to NSAIDs, but they appear superior to NSAIDs in improving shoulder abduction. This is particularly true for the painful stiff shoulder, as seen with impingement or rotator cuff disease.^26,28

Two recent randomized control trials showed corticosteroid injections to be superior to physical therapy for treatment of shoulder complaints.^12,13

Shoulder instability may be treated nonoperatively at first with PRI, NSAIDs, and strengthening and proprioceptive exercises for the rotator cuff. If 3 to 6 months of nonoperative treatment fails, the patient should be referred for surgical evaluation, especially in cases of full-thickness rotator cuff tears.¹⁴

TABLE 2
Nonoperative treatment options for shoulder pain

Treatment	Comment	SOR
NSAIDs	Appear superior to placebo in short-term treatment of shoulder pain Improve abduction in rotator cuff tendinitis Inconclusive effect on pain reduction No apparent difference between types of NSAIDs Steroid injection to supplement NSAIDs appears to confer no benefit	C
Physical therapy	Evidence is insufficient or absent to advocate use of low-level laser therapy, heat treatments, cold therapy, electrotherapy, and mobilization	B
Ultrasound	Ineffective compared with placebo	A
Steroid injection	Improves abduction in rotator cuff tendinitis Superior to NSAIDs in improving abduction Inconclusive data on efficacy in pain reduction	B
Acupuncture	Majority of high-quality studies show no benefit for chronic neck pain Weak evidence for short-term efficacy in patients with subacromial pain	C
SOR, strength of recommendation (SORT); NSAIDs, nonsteroidal anti-inflammatory drugs.

Treatment of specific shoulder disorders

Subacromial impingement syndrome stage I

A recommendation (SOR: B) can be made for the use of NSAIDs in the treatment of stage I impingement ( Table 3 ). This is based on level 2 evidence that NSAIDs are beneficial for rotator cuff tendinopathy and bicipital tendinitis, compared with placebo in a 1 to 2 week follow-up.^15,17 No specific NSAID has proved better than another.^18,19

Steroid injection ( Figure 2 ) is beneficial for the acute treatment of SIS I reflected by improvement in pain (SOR: A).^20-23 This is particularly evident during the first 1 to 2 weeks following injections.³⁸ At 4 to 6 weeks, there appears to be no difference in the efficacy of steroid injection compared with NSAIDs,^24,25 but they are both better than placebo.⁴³

Physical therapy, specifically rotator cuff strengthening and range of motion, is as beneficial as surgery for SIS I at 6 month and 2¹/2-year follow-up, and both were better than placebo (SOR: B).^26,27

TABLE 3
Treatments for SIS I impingement (rotator cuff tendinitis/tendinosis)

Treatment	Comment	LOE
NSAIDs	Benefit seen with use for 1 to 2 weeks	1c
NSAIDs vs steroid injection	Both better than placebo NSAIDs and injections are equally effective over 4 to 6 weeks	1a
Subacromial steroid injection	Most effective 1 to 2 weeks following injection	1b
Surgery	No statistically significant difference compared with physical therapy	2a

FIGURE 2
Steroid injection in the subacromial space

SIS stages II and III

There is very good evidence (SOR: B) regarding the efficacy of nonoperative treatment of SIS II and III, based on level 2 cohort studies that suggest nonoperative care leads to improvements in patient satisfaction, pain, and daily activities.^28,29Similar outcomes are reported for patients undergoing physical therapy alone.^30,31Weiss reported that corticosteroid injections for stage III/full-thickness rotator cuff tears resulted in an 86% improvement as measured by return to previous activities and less or no pain with motion ( Table 4 ).³²

The most constant outcome measure was report of a reduction in pain. Younger patients or those with higher functional demands will likely consider surgical repair if nonoperative measures fail, particularly for full-thickness tears.