Clinical Evidence Handbook

A Publication of BMJ Publishing Group

Shoulder Pain

Am Fam Physician. 2011 Jan 15;83(2):137-138.

This clinical content conforms to AAFP criteria for evidence-based continuing medical education (EB CME). See the CME Quiz.

Shoulder pain encompasses a diverse array of pathologies and can affect up to one-fourth of the population, depending on age and risk factors.

  • Shoulder pain may be due to problems with the neck, glenohumeral joint, acromioclavicular joint, rotator cuff, or other soft tissues around the shoulder.

Rotator cuff problems are the most common source of shoulder pain, accounting for more than two-thirds of cases.

  • Rotator cuff disorders are associated with musculoskeletal problems that affect the joints and muscles of the shoulder, cuff degeneration due to aging and ischemia, and overloading of the shoulder.

Frozen shoulder (adhesive capsulitis) accounts for 2 percent of cases of shoulder pain.

  • Risk factors for frozen shoulder include female sex, older age, shoulder trauma and surgery, diabetes mellitus, and cardiovascular, cerebrovascular, and thyroid disease.

In many persons, the cornerstone of treatment is achieving pain control to permit a return to normal functional use of the shoulder and encouraging this with manual exercises. In persons with acute posttraumatic tear, an early surgical option is warranted.

We do not know whether topical nonsteroidal anti-inflammatory drugs (NSAIDs), oral corticosteroids, oral paracetamol, or opioid analgesics improve shoulder pain, although oral NSAIDs may be effective in the short term in persons with acute tendonitis or subacromial bursitis. If pain control fails, the diagnosis should be reviewed and other interventions considered.

Physiotherapy may improve pain and function in persons with mixed shoulder disorders compared with placebo.

Intraarticular corticosteroid injections may reduce pain in the short term compared with physiotherapy and placebo for persons with frozen shoulder, but their benefit in the long term and when compared with local anesthetic is unclear.

Platelet-rich plasma injections may improve the speed of recovery in terms of pain and function in persons having open subacromial decompression for rotator cuff impingement, but further evidence is needed.

Acupuncture may not improve pain or function in persons with rotator cuff impingement compared with placebo or ultrasound.

Extracorporeal shock wave therapy may improve pain in calcific tendonitis.

We found some evidence that suprascapular nerve block, laser treatment, and arthroscopic subacromial decompression may be effective in some persons with shoulder pain.

We do not know whether autologous whole blood injections, intraarticular NSAID injections, subacromial corticosteroid injections, electrical stimulation, ice, ultrasound, rotator cuff repair, manipulation under anesthesia, excision of distal clavicle, or shoulder arthroplasty are effective because we found insufficient evidence on their effects.

Clinical Questions

What are the effects of oral drug treatment in persons with shoulder pain?

Likely to be beneficial

NSAIDs (oral; reduce pain in persons with acute tendonitis, subacromial bursitis, or both)

Unknown effectiveness

Corticosteroids (oral)

Opioid analgesics

Paracetamol

What are the effects of topical drug treatment in persons with shoulder pain?

Unknown effectiveness

NSAIDs (topical)

What are the effects of local injections in persons with shoulder pain?

Likely to be beneficial

Nerve block

Unknown effectiveness

Autologous whole blood injections

Intraarticular corticosteroid injections

Intraarticular NSAID injections

Platelet-rich plasma injections

Subacromial corticosteroid injections

What are the effects of nondrug treatment in persons with shoulder pain?

Likely to be beneficial

Extracorporeal shock wave therapy

Laser treatment

Physiotherapy (manual treatment, exercises)

Unknown effectiveness

Acupuncture

Electrical stimulation

Ice

Ultrasound

What are the effects of surgical treatment in persons with shoulder pain?

Likely to be beneficial

Arthroscopic subacromial decompression

Unknown effectiveness

Excision of distal clavicle

Manipulation under anesthesia

Rotator cuff repair

Shoulder arthroplasty


NSAID = nonsteroidal anti-inflammatory drug.

Clinical Questions

View Table

Clinical Questions

What are the effects of oral drug treatment in persons with shoulder pain?

Likely to be beneficial

NSAIDs (oral; reduce pain in persons with acute tendonitis, subacromial bursitis, or both)

Unknown effectiveness

Corticosteroids (oral)

Opioid analgesics

Paracetamol

What are the effects of topical drug treatment in persons with shoulder pain?

Unknown effectiveness

NSAIDs (topical)

What are the effects of local injections in persons with shoulder pain?

Likely to be beneficial

Nerve block

Unknown effectiveness

Autologous whole blood injections

Intraarticular corticosteroid injections

Intraarticular NSAID injections

Platelet-rich plasma injections

Subacromial corticosteroid injections

What are the effects of nondrug treatment in persons with shoulder pain?

Likely to be beneficial

Extracorporeal shock wave therapy

Laser treatment

Physiotherapy (manual treatment, exercises)

Unknown effectiveness

Acupuncture

Electrical stimulation

Ice

Ultrasound

What are the effects of surgical treatment in persons with shoulder pain?

Likely to be beneficial

Arthroscopic subacromial decompression

Unknown effectiveness

Excision of distal clavicle

Manipulation under anesthesia

Rotator cuff repair

Shoulder arthroplasty


NSAID = nonsteroidal anti-inflammatory drug.

Definition

Shoulder pain arises in or around the shoulder from its joints and surrounding soft tissues. Joints include the glenohumeral, acromioclavicular, and sternoclavicular joints. Bursae and motion planes include the subacromial bursa and scapulothoracic plane. Regardless of the disorder, pain is the most common reason for consulting a physician.

In frozen shoulder, pain is associated with pronounced restriction of movement. Rotator cuff disorders may affect one or more portions of the rotator cuff and can be further defined as subacromial impingement (rotator cuff tendonitis), rotator cuff tear (partial or full thickness), or calcific tendonitis. A subacromial or subdeltoid bursitis may be associated with any of these disorders, or may occur in isolation.

When selecting treatment options for shoulder pain, a diagnosis of the specific pathology is rarely necessary. The most useful aspect of diagnosis is to define the source of pain as originating from the cervical spine, glenohumeral joint, rotator cuff, or acromioclavicular joint. A simple algorithm incorporating identification of red flag symptoms and signs, questions in the history, and simple shoulder tests can be followed to locate the source of the shoulder pain.

Incidence and Prevalence

Each year in primary care in the United Kingdom, about 1 percent of adults older than 45 years present with a new episode of shoulder pain. Prevalence is uncertain, with estimates from 4 to 26 percent. One community survey (392 persons) in the United Kingdom found a one-month prevalence of shoulder pain of 34 percent. A second survey (644 persons 70 years and older), in a community-based rheumatology clinic in the United Kingdom, reported a point prevalence of 21 percent, with a higher frequency in women than men (25 percent in women versus 17 percent in men). Seventy percent of cases involved the rotator cuff. Further analysis of 134 persons included in the survey found that 65 percent of cases were rotator cuff lesions, 11 percent were caused by localized tenderness in the pericapsular musculature, 10 percent involved acromioclavicular joint pain, 3 percent involved glenohumeral joint arthritis, and 5 percent were referred pain from the neck. Another survey in Sweden found that in adults, the annual incidence of frozen shoulder was about 2 percent, and those 40 to 70 years of age were most commonly affected.

Etiology and Risk Factors

Rotator cuff disorders are associated with excessive overloading, instability of the glenohumeral and acromioclavicular joints, muscle imbalance, adverse anatomical features (narrow coracoacromial arch and a hooked acromion), rotator cuff degeneration with aging, ischemia, and musculoskeletal diseases that result in wasting of the cuff muscles.

Risk factors for frozen shoulder include female sex, older age, shoulder trauma, surgery, diabetes, cardiorespiratory disorders, cerebrovascular events, thyroid disease, and hemiplegia. Arthritis of the glenohumeral joint can occur in numerous forms, including primary and secondary osteoarthritis, rheumatoid arthritis, and crystal arthritides.

Shoulder pain can also be referred from other sites, in particular the cervical spine. It can also arise after stroke. Poststroke shoulder pain and referred pain are not addressed in this review.

Prognosis

One survey in a community of older persons found that most persons with shoulder pain were still affected three years after the initial survey. One prospective cohort study of 122 adults in primary care found that 25 percent of persons with shoulder pain reported previous episodes and 49 percent reported full recovery at 18 months' follow-up.


editor's note: Paracetamol is called acetaminophen in the United States.

search date: August 2009.

Author disclosure: Nothing to disclose.

Adapted with permission from Murphy R, Carr A. Shoulder pain. Clin Evid Handbook. December 2010:416-417. Please visit http://www.clinicalevidence.bmj.com for full text and references.

This is one in a series of chapters excerpted from the Clinical Evidence Handbook, published by the BMJ Publishing Group, London, U.K. The medical information contained herein is the most accurate available at the date of publication. More updated and comprehensive information on this topic may be available in future print editions of the Clinical Evidence Handbook, as well as online at http://www.clinicalevidence.bmj.com (subscription required). Those who receive a complimentary print copy of the Clinical Evidence Handbook from United Health Foundation can gain complimentary online access by registering on the Web site using the ISBN number of their book.

A collection of Clinical Evidence Handbook published in AFP is available at http://www.aafp.org/afp/bmj.


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