Shoulder Pain

Shoulder Pain

Shoulder pain is the second most common problem among the general population reporting musculoskeletal pain (Picavet & Schouten 2003) and accounting for 2.4% of all GP consultations in the UK (Linsell L 2006). In primary care around 1% of adults over 45 present with a new episode of shoulder pain (Mitchell C 2005), of which 44-74% suffer from subacromial pain (Ostor AJ 2005), (Roquelaure Y 2009), (Victoria A 2005).

In primary care around 1% of adults over 45 present with a new episode of shoulder pain each year (​Mitchell C 2005), with estimated costs of £310 million in the first 6 months (Kuijpers T 2006). Moreover approximately 30million/ year is an estimated cost for rotator cuff related surgical procedures (Littlewood C 2012)

Rotator cuff related shoulder pain hinders activities of daily living, including eating, dressing, and working (Bennell K 2007). Shoulder pain can persists for long duration with frequently poor long term outcome for a significant proportion of people who present for treatment (Lewis J 2009), leaving up to half of them in pain and/or functional disturbance for up to two years (Brueton, V.C., et al 2014).

Shoulder pain is the third most common reason for consultation with a physiotherapist (May S 2003) and is managed well in primary care by physiotherapists and GPs. 

Conservative treatment, including physiotherapy, is recommended as a first-line management approach (Dorrestijn O 2007)

Rotator cuff related shoulder pain should preferably be treated non-operatively and there is no evidence that surgical treatment is more effective than conservative management (Ron Diercks 2014).

Although the potential benefits of exercise over surgery in treatment of rotator cuff related shoulder pain have been reported in a systematic review (Littlewood C & Ashton J 2012), both conservative and surgical intervention are currently used to treat this condition (Littlewood C 2012).

Subacromial pain is the pain arising from the structures located in the subacromial space. Often variety of diagnostic labels such as subacromial impingement syndrome, rotator cuff tendinopathy, subacromial bursitis, supraspinatus tendinosis, and rotator cuff syndrome have been used as to describe subacromial pain creating uncertainty regarding the pathogenesis. The most common source of pain appears to be the subacromial bursa and the rotator cuff with the diagnostic label subacromial impingement syndrome (SIS) (Ostor AJ 2005), (Pribicevic M 2009).

SIS is frequently used in the literature and refers to the pain that arises when structures in the subacromial space (primarily the rotator cuff tendons and the subacromial bursa) are impinged between the humeral head and the acromion mainly during arm activity above the horisontal plane (Lewis JS, 2009), (Michener LA 2003).

The subacromial space is limited by the coracoacromial arch superiorly and by the humeral head inferiorly. The subacromial bursa and the tendons of the rotator cuff are situated within this space. During elevation of the arm the acromion and humeral head approach each other, narrow the subacromial space and impinge the subacromial structures Brossmann (J 1996). The recommended treatment for these patients is primarily non-surgical with a focus on exercise treatment (Hanratty CE 2012), (Kuhn JE 2009). If non-surgical intervention fails arthroscopic subacromial decompression (ASD) surgery followed by exercise treatment is recommended.