Clinical Question

Is corticosteroid injection more effective than physical therapy in the management of nontraumatic shoulder pain?

Bottom Line

Both physical therapy and corticosteroid injection decrease pain and disability by about 50% within one month of beginning treatment. However, average scores will not improve beyond that over the course of the year, and the average person will have pain, disability, and an altered quality of life one year later. Let patients know that neither treatment is a silver bullet for functional shoulder pain and that they are likely to have some long-term problems no matter which treatment they select. (Level of Evidence = 1b)

Synopsis

The investigators enrolled 104 adults who were referred for physical therapy from family medicine or orthopedic clinics. The patients had shoulder pain without evidence of trauma, rotator cuff tear, or cervical spine–related symptoms, and were loosely defined as having “shoulder impingement syndrome.” The patients (65% men; mean age of 42 years) were randomized, using concealed allocation, to receive six twice-weekly sessions of physical therapy or up to three subacromial injections of triamcinolone acetonide, 40 mg, over the course of a year. The physical therapy consisted of mobilization, stretching, and exercising based on an assessment of the patient's weakness, mobility, and pain. Home exercises were also prescribed. Patients in both groups improved quickly, with an approximately 50% improvement in shoulder pain and function as measured by the Shoulder Pain and Disability Index by one month, which was maintained in both groups over the subsequent 11 months. Similarly, pain scores and quality of life scores were improved. The average patient in either group still had residual pain and/or disability; 38% of patients in the corticosteroid group had more than one injection.

Study design: Randomized controlled trial (nonblinded)

Funding source: Industry

Allocation: Concealed

Setting: Outpatient (specialty)

Reference: RhonDIBoylesRBClelandJAOne-year outcome of subacromial corticosteroid injection compared with manual physical therapy for the management of the unilateral shoulder impingement syndrome: a pragmatic randomized trial. Ann Intern Med.2014; 161( 3): 161– 169.