Shoulder pain: diagnosis and management in primary care
BMJ 2005; 331 doi: https://doi.org/10.1136/bmj.331.7525.1124 (Published 10 November 2005) Cite this as: BMJ 2005;331:1124
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Pofessor Arroll is undoubtedly correct in his assessment of the
efficacy of corticosteroid injections for rotator cuff syndrome.
This efficay however, reflects symptomatic relief, as I am reminded
that cortisone acts by altering the tissue response and does nothing to
treat the cause.
Yes, Cyriax was a proponent of steroid injections as well, it seems
like such a cop-out though.
Manual manipulation as applied by osteopaths or chiropractors often
obtains objective improvement in a reasonable time span, thus I would
always consider this the treatment of choice.
Also, we ought not forget that many people who present with symptoms
that point toward RCS are in reality suffering from a problem in the
cervical spine and are misdiagnosed and given the easy treatment of
steroid injection.
When results fail to materialize it adds to the perception that the
evidence for this kind of management is weak.
Competing interests:
None declared
Competing interests: No competing interests
The authors report that the evidence for corticosteroids in shoulder
disorders is weak. This is perhaps because they only examined the Cochrane
reviews which did not report numbers needed to treat. I was part of a
review "Arroll B, Goodyear-smith F. Corticosteroid injections for painful
shoulder a meta-analysis. Br J Gen Pract 2005;55:224-8." where the the
relative risk (RR) for improvement for subacromial corticosteroid
injection for rotator cuff tendonitis was 3.1 (95%CI 1.9-4.9). This
translated to a numbers needed to treat of 3.3 to get an improvement which
is better than almost any thing we do in clinical medicine. The experience
of myself and some of my colleagues that this NNT translates in to
everyday clinical practice. There is an absence of data on harm but plenty
on effectiveness. Thus if we are cautious we can improve the situation for
our patients.
Competing interests:
None declared
Competing interests: No competing interests
I agree with Gavin Tait. Without proper diagnosis, treatment regimes
are more likely to be ineffective, i.e. we end up with Voltaire's
principle of simply entertaining the patient whilst nature takes its
course (for better or for worse).
Diagnostic triage for shoulder pain depends on the ability of the
clinician to accurately identify diagnostic sub-groups. The authors
suggest that this should be straight forward. However, the diagnostic
triage system for low back pain advocated some years ago by CSAG and the
RCGP does not appear to have improved back pain management in this
country.
This may be due to a failure of clinicians to adopt the principles of
diagnostic triage and acquire the skills to carry it out effectively. It
may also reflect that determination of many health care practitioners to
pursue evidence-weak treatments at all cost, simply to justify their
involvement in the care of the patient.
Acupuncture may have a role in the management of shoulder pain, but
the evidence for its use is weak. This does preclude its use, but it does
require the clinician to justify any treatment protocol on the basis of
accurate diagnosis and sound clinical reasoning.
Competing interests:
Member of Acupuncture Association of Chartered Physiotherapists
Competing interests: No competing interests
Congratulations to Andy Carr et al in highlighting the morbidity
associated with shoulder disease. However he misses the opportunity to
clarify the main problem in resolving shoulder problems; a correct
diagnosis of the source of the patients complaint. Many wasted hours of
physiotherapy, acupuncture and other treatments are suffered by patients
who are treated without first having a diagnosis. Only 3 paragraphs of a
5 page article and one table are given to diagnosis. All the common
shoulder complaints can be correctly identified by clinical history and
examination, so why are patients so often mistreated at length for the
wrong condition.
Too often shoulder pain is treated as just that: shoulder pain. The
shoulder is of 5 joints each of which can be the source of pain. Only by
identifying the source of the pain precicely can treatment be directed
correctly. No mention is made of the basic pattern of pain suffered when
one or other of the shoulder joints is diseased. The clinical assessment
described (Box 1)continues with the error of discussing shoulder pain as
one entity when there are several clear and recognised patterns of pain in
the shoulder which will usually accurately localise the presenting
disease.
The diagnosis of shoulder disease can be made with a clear
understanding of the clinical patterns of pain and associated signs. Only
then will treatment be properly targeted and effective. Maybe then
patients will be spared ineffectual and prolonged "holistic treatment"
with no clear scientific and clinical evidence base (See the other rapid
responses).
Competing interests:
None declared
Competing interests: No competing interests
To make a blanket statement about some alleged superior training of
either physiotherapists or doctors with training in CAM etc. contributes
little to the discussion.
In well over thirty years of practice, a good portion of which
involved Sport Medicine I was often impressed with the treatment results
of Osteopaths/Chiropractors, Acupuncturists and Massage Therapists.
Physiotherapy in the USA, Europe and Australia (personal experience
on the three continents) has often been a disappointment, notably because
of lengthy treatment regimens that seemed to kill time above all.
I had always put down these outcomes to the relative lack of comprehensive
training and relatively subservient position of physiotherapists but
remain open-minded.
Competing interests:
None declared
Competing interests: No competing interests
Sir/Madam
Richard states "However doctors and physiotherapists with training in
both allopathic and alternative therapies, meet the necessary safety
standards".
However, that statement is untrue when viewed from a TCM perspective
- remembering that acupuncture is a technique that was developed
effectively through, and has evolved safely from, TCM principles,
methodology and practices over hundreds of years. Modern Western medical
concepts cannot begin to explain the numerous mechanisms and fundamentals
of this technqiue, and therefore its safe use can only be expected to be
derived from a sound understanding of TCM doctrine, principles and
practices through which it evolved.
The doctrine has been used to diagnose, and the technique to treat,
musculo-skeletal conditions amongst many other conditions for generations
successfully and safely without western medical knowledge or intervention
and there is no reason to suppose that status quo needs altering for
phsyiotherapy or any other medical doctrine which cannot meet the
stringent approach TCM demands for safe efficacious use of one of its
technqiues.
Physiotherapy developed through a western medical doctrine and that
is fine for such usage; it cannot presume, nor can any other western
medically derived system of intervention, to be capable of using a
technqiue - called ACUpuncture for good reason - effectively and safely by
virtue of its background in western medicine.
Perhaps a useful way to demonstrate this would be for Richard to
describe a typical musculoskeletal condition with point prescription
typically applied with reasoning and allow me to explein typical TCM
considerations that may apply thereto?
Many physios are increasing their background knowledge of TCM
principles, I have taught a number myself, and that can only be a good
thing but in the main, I find that the average physio with "acupuncture
training" still appears to have limited understanding and knowledge of the
essentials of TCM that I would consider are a basic requirement for the
safe efficacious use of acupuncture.
Regards
John H.
Competing interests:
Specialist in TCM acupuncture & moxibustion
Competing interests: No competing interests
Papers of this type serve the primary care clinician well, as they
emphasis safety (recognition of Red Flags), and promote effectiveness
(i.e. enabling GPs and physiotherapists to recognise clinical patterns and
pursue evidence-based treatments).
Acupuncturists who have not been exposed to the type of vigorous
conventional medical training undertaken by doctors and allied
professionals, are simply not equipped with the appropriate safety
baseline for screening, diagnosing and managing musculo-skeletal
disorders.
However doctors and physiotherapists with training in both allopathic
and alternative therapies, meet the necessary safety standards and may
find papers of this type a welcome addition to their knowledge base.
I do not doubt for one minute that the inappropriate application of
TCM could lead to adverse events in the eyes of its followers. However,
the substition of a combined allopathic/acucopunture approach by TCM alone
may be a step too far.
Competing interests:
Member of the Acupuncture Association of Chartered Physiotherapists
Competing interests: No competing interests
Sir/Madam
In my last response I noticed, after publication unfortunately, I had
mistakenly said GB34 is used on the same and S38 opposite sides; this note
is to correct that - we use GB34 stimulation during acute frozen shoulder
on the opposite side to the affected shoulder and stimulate whilst asking
the patient to try gradually losen the shoulder through circular
movements; even the most painful 'stuck' (to use a useful expression of
one of my old teachers) shoulder can respond to this action at GB34. The
trick is to try maintain sufficient stimulation at GB34 (which can be
uncomfortable in itself) to induce loosening of the affected shoulder
whilst not producing too much stimulatory discomfort that the patient
cannot endure the acupuncture. This kind of stimulation is not common
generally and acupuncture usually does not involve considerable
discomfort, only such procedures.
For chronic frozen shoulder GB34 may be part of a prescription that,
for myself, often includes electroacupuncture between LI4 and GB21 on the
affected side and perhaps the "shoulder 3 point" prescription on the
affected side (LI15, Jian front and Jian rear points). Other points may be
combined depending on patient and symptoms.
S38 can often assist the process, as Tanya says, and is stimulated
rather like GB34 but on the affected side.
The constitution and unique charteristics of patient and condition
will dictate what prescription is used at each treatment.
Regards
John H.
Competing interests:
None declared
Competing interests: No competing interests
Sir/Madam
Tanya Trayers enthusiasm for the effectiveness of acupuncture is
certainly not misplaced although her apparent suggestion that a cheap
equally effective 'acupuncture service' might be gained from additional
training in the technique for physios, nurses, doctors and other medical
professionals, as compared to employing acupuncture professionals having
an extensive background in the doctrine that underpins the safest most
effective delivery of acupuncture, is certainly misplaced.
I suspect she does not appreciate the value of an extensive training
in traditional principles and methodologies that have underpinned the use
of acupuncture for generations. I welcome any opportunity to improve her
understanding in that regard.
The acupoint S38 is generally used to treat acute frozen shoulder at
the opposite side; for same side, GB34 is traditionally used for best
effect. Neither are as effective when the condition becomes more chronic
and other points are better used according to the location, type and
chronicity of disorder in each patient; both points must be used with
caution because, as their titles imply, S38 also has a powerful effect on
stomach function and GB34 on gall bladder function so patients with
underlying pathologies affecting those organs
a. might find those pathologies are affected positively or adversely
depending what kind of stimulation is applied and for how long to those
points and
b.might find the shoulder problem is a reflection of those
pathologies which are actually involved in causation of the frozen
shoulder symptoms
I find that such considerations are usually ignored, or not
understood at all, by practitioners unfamiliar with TCM doctrine and, as
such, they are incapable of recognising the full implications of their
acupuncture intervention.
In addition, anyone familiar with TCM would also be aware that
stimulation of any stomach point has a knock on effect to other organ
systems depending how stimulation is applied; for example over-
tonification or sedation of stomach points can affect heart, kidney, liver
and lung functions to different degrees; similarly for GB points, and
indeed any point selected. Those potential effects are predictable through
TCM considerations so acupoints are selected for simultaneous stimulation
according to a patient's individual state of health and constitution to
ensure a safe balance when any single point has been identified for
stimulation.
I hope Tanya is familiar with these essential considerations before,
as one of my old Chinese professors used to instill in his students, she
decides it RIGHT to insert an acupuncture needle into the right patient at
the right time in the right place.
Regards
John H.
Competing interests:
Specialist in Traditional Chinese Medicine - acupuncture & moxibustion
Competing interests: No competing interests
No treatment without diagnosis
It is unhelpful that the treatments recommended for the commonest
stated types of shoulder pain – rotator cuff disorders and gleno-humeral
and acromio-clavicular joint problems – are analgesics (obvious),
‘relative rest’ (whatever that means), encouragement of activity
(difficult when your shoulder hurts) and provision of a leaflet. The
impression is given that steroid injections for rotator cuff disorders
should be done reluctantly, and illogically into the subacromial bursa.
Practitioners are discouraged from injecting the shoulder joint since
apparently this needs to be guided by fluoroscopy. If patients are still
suffering after six months, referral for consideration for surgery is
suggested.
It may be that ‘the evidence for common primary care interventions,
including steroid injections, is relatively weak’, but this merely
reflects the fact that trials of specific treatments in accurately
diagnosed patients have not been done.
There are at least two current textbooks (1,2) setting out in detail
how to carry out a systematic clinical examination in patients with
shoulder pain, and how to treat them effectively with simple techniques
such as local steroid injections. It will be found that accurate
diagnoses can regularly be made, treatment can given to the part at fault,
and the great majority of such patients will thus be rapidly relieved of
their symptoms.
1. Ombregt L, Bisschop P, ter Veer H J. A System of Orthopaedic
Medicine, Churchill Livingstone, 2003.
2. Cyriax J. Textbook of Orthopaedic Medicine, Bailliere Tindall, 1982
Competing interests:
None declared
Competing interests: No competing interests