Approach to management

• There is a lack of well-designed trials on the common treatments for chronic shoulder disorders, but most people can be treated conservatively with some combination of activity modification, physical therapy, medication, and corticosteroid injection if necessary. This approach produces satisfactory results in the majority of people [Burbank et al, 2008].

Advice

• Articles on the management of shoulder pain in primary care [Hazleman, 2005; Mitchell, 2008] and a New Zealand guideline on the diagnosis and management of soft tissue shoulder injuries and related disorders [NZGG, 2004] recommend self-help advice and a discussion of physical contributory factors and analgesics.
• Reduction of precipitating movements (e.g. overhead activities) is advised, as this helps the person to avoid the painful arc between 60 and 120 degrees [Burbank et al, 2008].

Analgesia

• A New Zealand guideline on the diagnosis and management of soft tissue shoulder injuries and related disorders [NZGG, 2004], two articles on the management of shoulder pain in primary care [Hazleman, 2005; Mitchell, 2008], and a review of the treatment of chronic shoulder pain [Burbank et al, 2008] recommend analgesia for the pain of rotator cuff disorders.
• CKS found no evidence comparing paracetamol, nonsteroidal anti-inflammatory drugs (NSAIDs), or codeine for the treatment of shoulder pain caused by rotator cuff problems, therefore the decision should be based on clinical judgement, taking into account the person's symptoms, comorbidities, and:
• Limited evidence suggests that oral NSAIDs may reduce pain in people with acute tendonitis and/or subacromial bursitis, compared with placebo [Speed, 2008]. CKS found no systematic reviews or randomized controlled trials (RCTs) of topical NSAIDs, paracetamol, or opioid analgesia for shoulder pain.
• For more information on the adverse effect profile and contraindications to prescribing NSAIDs, see the CKS topic on NSAIDs - prescribing issues.
• CKS has not recommended the use of stronger opioids in primary care as they are generally reserved for people with moderate-to-severe pain, and long-term treatment should be undertaken with caution because of the potential for dependence [Iannotti and Kwon, 2005].

Physiotherapy/exercise

• A New Zealand guideline on the diagnosis and management of soft tissue shoulder injuries and related disorders [NZGG, 2004], two articles on the management of shoulder pain in primary care [Hazleman, 2005; Mitchell, 2008], and a review of the treatment of chronic shoulder pain [Burbank et al, 2008] recommend physiotherapy for rotator cuff disorders. The goal of physical therapy is to optimize the shoulder joint function [Burbank et al, 2008].
• There is limited evidence that a supervised exercise regimen is of benefit in the short and long term for mixed shoulder disorders and rotator cuff disorder [Green et al, 2003] and that exercise therapy, in combination with other treatments, is effective in reducing pain in people with impingement syndrome [Trampas and Kitsios, 2006].
• Other treatments which may be offered by a physiotherapist include ultrasound, massage, and a gradual regimen of mobilization, stretching, and cuff-strengthening exercises [Hazleman, 2005].
• The relative benefits of physiotherapy compared with corticosteroid injections remain unclear [NZGG, 2004], although limited evidence suggests that for rotator cuff disorder, corticosteroid injections are superior to physiotherapy interventions [Green et al, 2003].

Corticosteroid injections

• A New Zealand guideline on the diagnosis and management of soft tissue shoulder injuries and related disorders [NZGG, 2004], two articles on the management of shoulder pain in primary care [Hazleman, 2005; Mitchell, 2008], and reviews of the treatment of chronic shoulder pain [Moskowitz and Blaine, 2005; Burbank et al, 2008] recommend corticosteroid injections for the treatment of some rotator cuff disorders.
• Timing:
• It is uncertain when, in relation to analgesia and physiotherapy, corticosteroid injections should be considered.
• An article on the management of shoulder pain in primary care suggests that steroid injections should always be used in conjunction with analgesia and mobilizing physiotherapy [Hazleman, 2005]. Response to corticosteroid injection is usually rapid, and may increase the benefits of physical therapy in people with rotator cuff disorders and adhesive capsulitis [Iannotti and Kwon, 2005; Moskowitz and Blaine, 2005].
• Two reviews suggest injecting after analgesia and physiotherapy have been tried (unless function is initially severely limited by pain) and suggest a subacromial corticosteroid injection may provide significant pain control that allows an improved range of motion and better tolerance of physical therapy (if the person has made little progress after several weeks, or has very limited function because of initial pain) [Moskowitz and Blaine, 2005; Burbank et al, 2008].
• The relative benefits of corticosteroid injection compared with physiotherapy remain unclear [NZGG, 2004] although limited evidence suggests that for rotator cuff disorder, corticosteroid injections are superior to physiotherapy interventions [Green et al, 2003].
• Choice of corticosteroid and use of lidocaine:
• CKS found no guidelines informing the choice of corticosteroid. A number of corticosteroid preparations are listed in the British National Formulary [BNF 55, 2008], but feedback from expert reviewers suggested that triamcinolone or methylprednisolone are the most commonly used.
• Feedback from expert reviewers also suggested that local anaesthetic is commonly used in conjunction with a corticosteroid. Reasons given for this included that local anaesthetic can give immediate pain relief, can help confirm the diagnosis, and may decrease the risk of steroid atrophy by diluting the corticosteroid.
• It is uncertain from the available evidence whether the combination of subacromial corticosteroid injections plus lidocaine improves pain, function, or range of movement, or activities of daily living, compared with lidocaine alone [Buchbinder et al, 2003; Speed, 2008].
• Number of injections:
• Acute rotator cuff tendinitis can respond to corticosteroid injections, but no more than three should be given in a year [Silver, 2002]. It is usual to avoid injections if there is clinical evidence of a rotator cuff tear [Hazleman, 2005]. A review advises that local injection with corticosteroids should not be given if minimal or no benefit was obtained from previous injections [Iannotti and Kwon, 2005].
• Adverse effects:
• CKS advises discussion of adverse effects when considering subacromial corticosteroid injections. These include infection (rare if sterile technique used), tendon rupture, and hyperglycaemia in people with diabetes [NZGG, 2004]. Feedback from an expert reviewer suggests other adverse effects including local tissue atrophy, flushing, and menstrual disorders in women.
• A New Zealand guideline advises monitoring blood glucose in people with diabetes after corticosteroid injection, as this may be elevated for 24–48 hours [NZGG, 2004].
• Feedback from expert reviewers suggests that it may be preferable to defer steroid injections until diabetes is well controlled, and that the risk of infection should be carefully considered in a person with diabetes.

• CKS has based the timescale for referral on a number of sources. A New Zealand guideline on the diagnosis and management of soft tissue shoulder injuries and related disorders suggests referral to orthopaedics if tendinosis symptoms fail to improve at 6 months or longer [NZGG, 2004]. One review suggested that if the rotator cuff is thought to be intact (i.e. no tear is suspected) a 3–6 month trial of conservative treatment is considered adequate before referral [Burbank et al, 2008], and another suggested referral if the person has persistent pain after a 3-month course of physical therapy [Codsi, 2007].
• If a large tear is suspected (e.g. the person has a history of acute trauma, weakness, or active elevation < 120 degrees) a magnetic resonance imaging (MRI) scan should be obtained and a prompt referral is indicated [Iannotti and Kwon, 2005; Codsi, 2007; Burbank et al, 2008].
• Urgent referral if red flag features are present is recommended in an article on the management of shoulder disorders in primary care [Mitchell et al, 2005].