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Exercise therapy after corticosteroid injection for moderate to severe shoulder pain: large pragmatic randomised trial

BMJ 2010; 340 doi: (Published 28 June 2010) Cite this as: BMJ 2010;340:c3037
  1. Dickon P Crawshaw, extended scope practitioner physiotherapist12,
  2. Philip S Helliwell, senior lecturer2,
  3. Elizabeth M A Hensor, statistician3,
  4. Elaine M Hay, professor of community rheumatology4,
  5. Simon J Aldous, extended scope physiotherapy practitioner specialising in shoulders5,
  6. Philip G Conaghan, professor of musculoskeletal medicine23
  1. 1Leeds Musculoskeletal and Rehabilitation Service, Leeds Community Healthcare, Leeds LS7 4SA
  2. 2Section of Musculoskeletal Disease, Leeds Institute of Molecular Medicine, University of Leeds, Leeds LS7 4SA
  3. 3NIHR Leeds Musculoskeletal Biomedical Research Unit, Chapel Allerton Hospital, Leeds LS7 4SA
  4. 4Arthritis Research UK National Primary Care Research Centre, Keele University, Keele, Staffordshire ST5 5BG
  5. 5Physiotherapy Department, Leeds Teaching Hospitals NHS Trust, Leeds LS9 7TF
  1. Correspondence to: P Conaghan p.conaghan{at}
  • Accepted 8 April 2010


Objective To compare the effectiveness of subacromial corticosteroid injection combined with timely exercise and manual therapy (injection plus exercise) or exercise and manual therapy alone (exercise only) in patients with subacromial impingement syndrome.

Design Pragmatic randomised clinical trial.

Setting Primary care based musculoskeletal service.

Patients Adults aged 40 or over with subacromial impingement syndrome with moderate or severe shoulder pain.

Interventions Injection plus exercise or exercise only.

Main outcome measures Primary outcome was the difference in improvement in the total shoulder pain and disability index at 12 weeks.

Results 232 participants were randomised (115 to injection plus exercise, 117 to exercise only). The mean age was 56 (range 40-78), 127 were women, and all had had a median of 16 weeks of shoulder pain (interquartile range 12-28). At week 12 there was no significant difference between the groups in change in total pain and disability index (mean difference between change in groups 3.26 (95% confidence interval −0.81 to 7.34), P=0.116). Improvement was significantly greater in the injection plus exercise group at week 1 (6.56, 4.30 to 8.82) and week 6 (7.37, 4.34 to 10.39) for the total pain and disability index (P<0.001), with no differences at week 24 (−2.26, −6.77 to 2.25, P=0.324).

Conclusions In the treatment of patients with subacromial impingement syndrome, injection plus exercise and exercise only are similarly effective at 12 weeks.

Trial registration ISRCT 25817033; EudraCT No 2005-003628-20.


  • We thank the participating physiotherapists (L Ackerman, D Aldous, S Banerjee, R Batley, R Bodey, F Brown, N Clay, K Charman, C Comer, J Cousins, S Dadswell, V Doemling, J Flint, S Foster, J Glover, N Henderson, A Ibison, V Johnstone, E Jones, N Jones, T Langford, J Muirhead, E Newton, R Osborn, M Oxley, R Partner, J Patterson, G Reader-Peate, A Reilly, J Smith, S Smith, J Sneath, A Thompson, K Thompson, B Urquhart, S Urquhart, S Walby, D Walker, A White), the management and administration staff at Leeds Musculoskeletal and Rehabilitation Service (L Berry, W Brocklehurst, T Butterfield, C Cagna, A Griffiths, V Hughes, S Johnson, D Lambert, C McNamara, J Moody, J Rogers, S Strickland), the research assistant (K Lewis), and the patients who made the trial possible. We also thank J Klaber Moffett for her advice on the original study proposal and the Institute of Rehabilitation, University of Hull, for providing the telephone randomisation service.

  • Contributors: All authors participated in the planning of the study and contributed to the protocol. EMAH analysed the data. DPC drafted the manuscript, which was revised by the other authors. PGC is guarantor.

  • Funding: The study was funded by a project grant 17236 from Arthritis Research UK.

  • Competing interests: All authors have completed the Unified Competing Interest form at (available on request from the corresponding author) and declare that (1) DPC and PGC have support from Arthritis Research UK for the submitted work. All authors declare no interests under (2), (3), and (4).

  • Ethical approval: This study was approved by the local research ethics committee, and informed consent was given by all patients.

  • Data sharing: The dataset will be available from the corresponding author as part of an academic collaboration.

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