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Effect of specific exercise strategy on need for surgery in patients with subacromial impingement syndrome: randomised controlled study

BMJ 2012; 344 doi: (Published 20 February 2012) Cite this as: BMJ 2012;344:e787
  1. Theresa Holmgren, PhD student1,
  2. Hanna Björnsson Hallgren, PhD student2,
  3. Birgitta Öberg, professor1,
  4. Lars Adolfsson, professor2,
  5. Kajsa Johansson, senior lecturer1
  1. 1Department of Medical and Health Sciences, Division of Physiotherapy, Linköping University, SE- 581 83, Linköping, Sweden
  2. 2Department of Orthopaedics, University Hospital, SE-581 85, Linköping
  1. Correspondence to: T Holmgren theresa.holmgren{at}
  • Accepted 25 November 2011


Objective To evaluate if a specific exercise strategy, targeting the rotator cuff and scapula stabilisers, improves shoulder function and pain more than unspecific exercises in patients with subacromial impingement syndrome, thereby decreasing the need for arthroscopic subacromial decompression.

Design Randomised, participant and single assessor blinded, controlled study.

Setting Department of orthopaedics in a Swedish university hospital.

Participants 102 patients with long standing (over six months) persistent subacromial impingement syndrome in whom earlier conservative treatment had failed, recruited through orthopaedic specialists.

Interventions The specific exercise strategy consisted of strengthening eccentric exercises for the rotator cuff and concentric/eccentric exercises for the scapula stabilisers in combination with manual mobilisation. The control exercise programme consisted of unspecific movement exercises for the neck and shoulder. Patients in both groups received five to six individual guided treatment sessions during 12 weeks. In between these supervised sessions the participants performed home exercises once or twice a day for 12 weeks.

Main outcome measures The primary outcome was the Constant-Murley shoulder assessment score evaluating shoulder function and pain. Secondary outcomes were patients’ global impression of change because of treatment and decision regarding surgery.

Results Most (97, 95%) participants completed the 12 week study. There was a significantly greater improvement in the Constant-Murley score in the specific exercise group than in the control exercise group (24 points (95% confidence interval 19 to 28.0) v 9 points (5 to 13); mean difference between group: 15 points (8.5 to 20.6)). Significantly more patients in the specific exercise group reported successful outcome (defined as large improvement or recovered) in the patients’ global assessment of change because of treatment: 69% (35/51) v 24% (11/46); odds ratio 7.6, 3.1 to 18.9; P<0.001. A significantly lower proportion of patients in the specific exercise group subsequently chose to undergo surgery: 20% (10/51) v 63% (29/46); odds ratio 7.7, 3.1 to 19.4; P<0.001).

Conclusion A specific exercise strategy, focusing on strengthening eccentric exercises for the rotator cuff and concentric/eccentric exercises for the scapula stabilisers, is effective in reducing pain and improving shoulder function in patients with persistent subacromial impingement syndrome. By extension, this exercise strategy reduces the need for arthroscopic subacromial decompression within the three month timeframe used in the study.

Trial registration Clinical trials NCT01037673


  • We acknowledge the support and contribution of the physiotherapy orthopaedic department of the University Hospital in Linköping, Sweden. We also thank Henrik Magnusson for all statistical assistance.

  • Contributors: TH, HB, BÖ, LA, and KJ conceived and designed the study protocol. KJ and BÖ procured the project funding. TH and KJ designed the physiotherapy interventions. TH did the statistical analyses with assistance from a statistician employed at the department of medical and health sciences. HB was the blinded assessor. TH drafted the manuscript, and BÖ, HB, LA and KJ contributed to the manuscript. All authors read and approved the final manuscript. KJ is guarantor.

  • Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. TH is funded in part by the research council in the south east of Sweden (FORSS).

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: The study was approved by the ethics committee in Linköping (dnr: M124-07), and informed consent was given by all participants.

  • Data sharing: Physiotherapy protocols, statistical code, and dataset are available from the corresponding author.

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