Diercks R, Bron C, Dorrestijn O, et al. Guideline for diagnosis and treatment of subacromial pain syndrome. Acta Orthop. 2014;85:314–322.
Clinical Question: What new outlook does previous literature give on the guidelines for the treatment of subacromial pain syndrome (SAPS)?
Data Sources: The Netherlands Orthopedic Society (NOV) created a working group of clinicians with a common interest and expertise in clinical shoulder issues. The representatives from the NOV created eight clinical questions that included the following topics: prognosis of SAPS, effective measures of prevention of SAPS, the most accurate, sensitive, and specific physical diagnostic tests for SAPS, added value of imaging for diagnosis, most suitable instruments for measuring outcomes for SAPS, most effective conservative treatment, indication for and technique of surgical treatment, and advice for patients with SAPS. Studies were included if they matched specific search terms for each clinical question and were published in the English, Dutch, French, or German languages. Existing international guidelines were identified through the Guidelines International Network and the Quality Dome and Artsennet databases, whereas systematic reviews were found through Medline (OVID) and the Cochrane Library.
Study Selection: Thirty articles were included for the sixth clinical question, which focused on the most effective conservative treatment. The studies' levels of evidence ranged from level 1 to 3.
Data Extraction: Articles were selected based on the inclusion criteria above and on Grading of Recommendations Assessment, Development, and Education evidence levels of intervention studies and EBRO (the Dutch platform) evidence levels of diagnostic accuracy research or research of etiology/prognosis. After the literature search, each article was defined by a level of recommendation and the working group determined a general overall recommendation/conclusion of results for each clinical question following the highest level of recommendation. Each study's level of recommendation was based on the literature underlying the conclusions of that study's results.
Main Results: Five articles (level 1 to 2) assessed exercise therapy, whereas one article (level 1 to 2) compared manual joint mobilizations to active exercises. Four articles (level 2) examined the effects of massage on shoulder function. Finally, 16 articles (level 3) examined other interventions, including two studies that examined oral nonsteroidal anti-inflammatory drugs (NSAIDs), five studies that assessed all types of laser treatment, five articles that compared ultrasound to other therapies, three articles that examined electrical stimulation, and one study that compared acupuncture to a placebo and exercise therapy. The working group reported several considerations within the articles, such as the interchangeable use of the terms shoulder pain and SAPS, lack of documented co-interventions, complications, effectiveness of clinician advice, and lack of literature on behavioral therapy.
Conclusions: Non-operative treatment for SAPS should begin with rest and NSAIDs for the first 2 weeks, followed by increased activity. Corticosteroid injections are indicated for severe pain during the first 8 weeks. However, long-term use of injections is not recommended. Extracorporeal shockwave therapy may be used for subacromial calcium deposits, but not in the acute phase. Exercises should focus on eccentric movements at a low intensity and high frequency. Treating trigger points and scapular stabilization training should be considered.
Summary: Shoulder injuries are common among the general population, with up to 34% of adults reporting shoulder pain.1 SAPS accounts for approximately 50% of all shoulder pain cases.2 SAPS is an umbrella term used to describe pathologies affecting the structures in the subacromial space, which include enlarged bursa, bicep tendon tear/rupture, and rotator cuff tendon degeneration/tear.2 Physical therapy and steroid injections are common treatments for SAPS that have been studied for short-term effects.2–4 Steroid injections are a direct approach to treating symptoms and relieving pain, whereas physical therapy is an indirect approach to treating symptoms by strengthening the musculature of the shoulder with the goal of decreasing the recurrence of SAPS. Nevertheless, SAPS can reoccur and, therefore, the long-term effects of injections and exercise therapy need to be examined.
Diercks et al.1 suggested that increasing muscular strength of the shoulder through exercise therapy is more effective in minimizing pain and loss of function than no treatment. More specifically, exercises that focus on stabilizing the scapula and strengthening the rotator cuff muscles are the most effective.
Similarly, Savoie et al.5 had positive results in a study that examined movement training, strengthening, manual therapy, and stretching to target deficits in individuals with SAPS. Participants aged 18 to 65 years were included if they were clinically diagnosed as having SAPS based on positive findings within each of the following three categories: pain during shoulder flexion and abduction, positive impingement during the Kennedy-Hawkins or Neer test, and pain with resisted shoulder abduction, external rotation, and empty-can test.5 When clinically diagnosed, the study participants performed three phases of strengthening5: rotator cuff muscle exercises with a neutral positioned humerus (phase 1), shoulder elevation (phase 2), and trunk strengthening and endurance training (phase 3).5 This progression may be used to increase muscular strength, which, in turn, will decrease the likelihood of SAPS reoccurring.
In addition to exercise, Diercks et al.1 noted that corticosteroid injections were a more effective short-term treatment of symptoms than placebo injections or physiotherapy (the effects lasting up to 8 weeks).1 Gutierrez et al.3 compared outcomes for different injections with and without NSAIDs, as well as physiotherapy interventions.3 They found that, in comparison to anesthetic injections, steroid injections provided better relief of pain and function within 4 weeks.3 They also compared steroid injections, oral NSAIDs alone, and steroid injections taken with NSAIDs and found no significant differences in outcome measures for shoulder pain.3 Finally, physiotherapy was compared to steroid injections and, similarly to Diercks et al.,1 Gutierrez et al.3 concluded that injections should only be used for direct short-term treatment and outcomes for shoulder pain. Nevertheless, the locations of injection sites and the types of physiotherapy were not consistent across the studies, leading to an inappropriate summary.3 Both reviews stated short-term use of injections should occur within 3 to 7 weeks3 or fewer than 8 weeks in total.1
Although literature has provided specific guidelines of short-term use and effects of injections, long-term effects have not been thoroughly addressed. Diercks et al.1 was unable to conclude on a specific long-term protocol for injections, although it was recommended to refrain from using corticosteroid injections as a single long-term therapy. Gutierrez et al.3 specifically concluded that injections had little to no benefit over physiotherapy for improvements in shoulder pain lasting 6 to 52 weeks.
Two randomized trials2,4 compared injections to other therapies and focused on measuring long-term outcomes. Although methods and results differed, both trials indicated that the addition of exercise may increase positive outcomes, whether or not the exercise is combined with steroid injections.
In one trial, four patients (aged 18 years and older) with clinically diagnosed unilateral shoulder pain were randomized into either the physiotherapy or corticosteroid injection group.4 The injection group received one injection and, if their symptoms persisted, after 4 weeks could return to receive one more injection.4 Physiotherapy treatments lasted for 6 weeks and consisted of eight 20-minute sessions focusing on active shoulder exercises reinforced with home exercise plans, manual therapy, and ultrasonography. At the 6-month follow-up, the physiotherapy group showed a greater improvement (although not significant) in their scores on the shoulder disability questionnaire than the injection group.4
Ellegaaard et al.2 also used a 6-month follow-up, but they combined injections with exercise in the hope that it would lead to greater long-term improvement in patients with SAPS. Participants were included if they were clinically diagnosed as having unilateral shoulder pain that lasted at least 4 weeks and had an enlarged subacromial bursa, which was assessed through ultrasound imaging.2 One group of patients received the combined treatment, whereas the other group received injections only (two injections 1 week apart).2 The 10-week exercise program focused on scapula muscle stabilization and strength during the first 2 weeks and progressive strengthening for the following 8 weeks.2 At both the 13-and 26-week follow-up, there were no significant differences between groups for pain reduction during rest and activity, thickness of subacromial bursa, self-reported shoulder function, clinical impingement test results, and isometric muscle strength.2 However, at the 13-week follow-up, the combined treatment group had significantly fewer participants with a positive ultrasound impingement test than the injection group.2
The findings of this systematic review produced strong evidence that although steroid injections may be used for short-term pain relief, they may not produce long-term relief for patients with SAPS.1–4 Therefore, other treatment methods can be used with or without steroid injections. Rest and NSAIDs can be beneficial for pain control during the first 2 weeks,1 and exercise may be used separately or in combination to reach desired outcomes (eg, decreased pain relief and increased shoulder function).1,2,4,5 These interventions may decrease the recurrence of SAPS and therefore minimize the need for additional treatments.1,2,4,5 When treatment is focused on exercise therapy, a general progression could be gradually adding shoulder elevation, trunk strengthening, and endurance training to rotator cuff strengthening exercises.5 Scapular stabilization, critiquing proper posture, and eccentric exercises should be included in progressive therapy, whereas manual therapy may be used to treat trigger points on affected shoulders.1,5 Nevertheless, the choice of exercise, injections, or a combination solely depends on patient and physician preference and individual assessment.2 Because SAPS is a common issue among shoulder pathologies,2 this review can be useful for clinical practice by giving clinicians the knowledge to present options for patients seeking pain relief.
- Diercks R, Bron C, Dorrestijn O, et al. Guideline for diagnosis and treatment of subacromial pain syndrome: a multidisciplinary review by the Dutch Orthopaedic Association. Acta Orthop. 2014;85:314–322. doi:10.3109/17453674.2014.920991 [CrossRef]
- Ellegaard K, Christensen R, Rosager S, et al. Exercise therapy after ultrasound-guided corticosteroid injections in patients with subacromial pain syndrome: a randomized controlled trial. Arthritis Res Ther. 2016;18:129. doi:10.1186/s13075-016-1002-5 [CrossRef]
- Gutierrez G, Burroughs M, Podder S. Clinical inquiries. Does injection of steroids and lidocaine in the shoulder relieve bursitis?J Fam Prac. 2004;53:488–492.
- Hay EM, Thomas E, Peterson SM, Dziedzic K, Croft PR. A pragmatic randomised controlled trial of local corticosteroid injection and physiotherapy for the treatment of new episodes of unilateral shoulder pain in primary care. Ann Rheum Dis. 2003;62:394–399. doi:10.1136/ard.62.5.394 [CrossRef]
- Savoie A, Mercier C, Desmeules F, Frémont P, Roy JS. Effects of a movement training oriented rehabilitation program on symptoms, functional limitations and acromiohumeral distance in individuals with subacromial pain syndrome. 2015;20:703–708. doi:10.1016/j.math.2015.04.004 [CrossRef]