The Dutch College of General Practitioners (NHG) Practice Guideline
This NHG Practice Guideline is a translation of the Dutch guideline. It is specifically written for Dutch general practitioners in the Dutch enviroment. The advice which is given may therefore not be in accordence with the views of general practitioners in other countries.
J.C. Winters, A.C. de Jongh, D.A.W.M. van der Windt, M. Jonquière, A.F. de Winter, G.J.M.G. van der Heijden, J.S. Sobel, A.N. Goudswaard
The guideline and its scientific basis have been updated with respect to the previous version (Huisarts Wet 1990;5:196-202). The recommendations have been revised. The most important changes are:
The NHG Practice Guideline 'Shoulder complaints' provides guidance for the diagnosis and treatment of these complaints, which are defined as pain at rest or during movement of the upper arm, in part or all of the area between the base of the neck and the elbow (see illustration).
Shoulder complaints resulting from recent trauma are not included.1
The incidence of shoulder complaints in general practice is 15-25 per 1,000 patients per year, but the prevalence in the general population is 100-160 per 1,000.2 This indicates that a substantial number of people with shoulder complaints do not consult the general practitioner.
Shoulder complaints often have a recurrent and lengthy clinical course. They can have detrimental effects on activities during the day and on sleep at night, especially in the acute phase. The limits on daily functioning are specifically related to the severity of the pain during movement and the occurrence of pain at night. In half of the patients who consult the general practitioner the problem is resolved in 6 weeks. Patients with serious symptoms usually improve significantly in 2 weeks. After 1 year, however, about 40% of the patients have new or ongoing symptoms, even though most do not consult the general practitioner about them again.3
The cause of most shoulder complaints is in or near the shoulder joint. Which structure is affected usually cannot be determined accurately. Hence the term 'shoulder complaints' will also be used as both a working and a final diagnosis.
The guideline indicates when less common causes of shoulder complaints should be considered. These include functional disorders of the cervicothoracic spine,4 cervical radicular syndrome, rheumatic diseases, and disorders of organs that are not part of the locomotor apparatus, such as the heart, gallbladder, and lung.5 The management of shoulder complaints due to these causes is beyond the scope of this guideline.
The first version of this guideline, in 1990, was largely based on the Cyriax classification system, which is frequently used for shoulder disorders.6 Based on the anamnesis, testing of passive and active ranges of motion ('function testing'), and resistance tests, various syndromes were defined, such as the capsular syndrome, the subacromial syndrome, acute or chronic bursitis, and various forms of tendinitis. This complex classification system involves assumptions about the anatomical localization of the disorder, but good systematic research on its validity is lacking.
Since publication of the original version of the guideline, several studies have revealed limitations of the Cyriax system. The unreliability of various Cyriax diagnostic categories leads to much interobserver disagreement in the assessment of shoulder complaints.7 Further diagnostic differentiation often fails to result in more specific therapy, because there are few options for treating shoulder complaints available to the general practitioner. The reverse is also true, that the limited range of interventions available makes extensive classification of shoulder complaints meaningless.
For these reasons, a simple, pragmatic approach has been chosen in this revision of the guideline, based as far as possible on scientific research as well as suitability for use in general practice. The physical examination has been changed and simplified. Management consists of providing information, a policy of watchful waiting, and prescription of analgesics if needed. If there is insufficient improvement, a local corticosteroid injection can be given. If the patient continues to have serious limitations in daily activities, referral to a physical therapist can be considered.
The majority of complaints in the shoulder area are caused by shoulder disorders. They probably result from strain, aseptic inflammation, or degeneration of the soft tissues (muscles, tendons, joint capsules, and bursae) of the glenohumeral joint or of the structures in the immediate surroundings, such as the acromioclavicular joint. A reliable, anatomically-based diagnostic classification is not possible, but in many patients the clinical picture can be used to distinguish between shoulder complaints with and without limited passive range of motion.8
Shoulder complaints without limited passive range of motion
Pain occurs during or at the end of a movement trajectory, most often active and/or passive abduction, without limiting the movement result. The pain is thought to involve one or more structures in the subacromial space. Pain during active abduction is termed a 'painful arc'.9 This category of shoulder complaints also includes symptoms resulting from glenohumeral joint instability or acromioclavicular or sternoclavicular joint disorders. These disorders are thought to occur most often in combination with other shoulder problems. Because of this and their low incidence in general practice, they are not discussed as distinct clinical entities in this guideline.10
Shoulder complaints with limited passive range of motion
This is a passive, painful limitation of movement of the glenohumeral joint in one or more directions. It is assumed to be caused by aseptic inflammation of the glenohumeral joint capsule11 or subacromial structures.12
The source of shoulder pain is occasionally outside the shoulder area.
The pain may be 'referred', meaning that it is due to a problem elsewhere in the body. Most cases of referred pain arise from dysfunction of the cervical or thoracic spine. Active and passive movement of the neck usually causes not only neck pain but also radiating pain in the shoulder or the arm.
In rare cases, shoulder complaints are caused by other, more or less serious disorders. These include cervical radicular syndrome, rheumatic disease (rheumatoid arthritis and polymyalgia rheumatica), and internal diseases (such as coronary disease, abdominal disorders causing diaphragmatic irritation, pulmonary diseases, and local metastases). These disorders usually cause serious, persistent complaints and attendant symptoms, such as general feeling of illness and weight loss.5
In diagnosis, the general practitioner must be alert to the possibility of rare, sometimes serious, causes of shoulder pain. These should be considered when symptoms do not fit the usual clinical picture of shoulder complaints. The most common signs and the associated differential diagnostic considerations are: 5
Next, the general practitioner tries to gain an impression of the nature and severity of the complaints, partly for reference in follow-up examinations. Diagnostic classification based on movement testing is mainly relevant to treatment with a local injection (see under Management Guidelines).
Expose the area of the shoulder.
Other tests such as resistance tests, horizontal adduction, and passive endorotation need not be performed, since they do not provide enough information to affect the treatment policy. If no abnormalities are found in the above tests, do the following:
For most shoulder complaints, additional tests (x-ray, MRI, CT, or ultrasonography) are unnecessary, because the results rarely influence the general practitioner's treatment policy.15
The diagnosis shoulder complaints is made when there is pain in the shoulder area combined with abnormalities in shoulder movement revealed by testing. A distinction is made between:
If the clinical picture is mixed, identify the most prominent findings.
When there is pain in the shoulder area but no abnormalities are revealed by movement testing, a dysfunction of the cervicothoracic spine is considered: neck pain at rest or during neck movement, abnormal findings in preliminary tests of neck movement.
These guidelines are for shoulder complaints. Treatment begins with information and advice, followed by analgesics if necessary. If there is insufficient improvement within 2 weeks, a corticosteroid can be injected locally. The classification made in the evaluation is used to assess improvement.
Explain to the patient that shoulder complaints are caused by irritation of one of the structures in the shoulder but that the exact location cannot be determined with certainty. Emphasize that the clinical course is difficult to predict and that recovery can take weeks to months. The following characteristics are usually associated with a benign clinical course:16
Provide information about what can be offered to reduce pain and hasten recovery, i.e., analgesics, local injections, and remedial therapy. Explain that none of these treatments has been shown to significantly affect the natural long-term clinical course. In addition, make recommendations appropriate to a time-contingent approach, as follows:17
Application of ice packs, liniments, or heat, and performing special exercises (swinging, dangling), have not been tested sufficiently to allow well-founded judgements of their positive or negative effects.18
The usefulness of referral to a physical therapist in the acute phase (for physical therapy or manual therapy) has also not been evaluated adequately by well-designed studies.18 Referral during the first 6 weeks is not advisable, because the clinical course is often benign and the general practitioner can treat with analgesics and local injections, if needed. After 6 weeks, referral can be considered for complaints clearly causing limitations of daily functioning. In this case, an activating, time-contingent approach is preferred, with the aim of preventing chronic dysfunction. No clinically relevant effect on the course of shoulder complaints has been gained from technical applications such as ultrasound, transcutaneous electrical nerve stimulation (TENS), or interference current. These treatments are not advised.
If analgesia is necessary, prescribe paracetamol for a period of two weeks (4 times daily, maximum 4,000 mg/day). Second-choice alternatives, or if the response to paracetamol is unsatisfactory, are ibuprofen (3 times daily, maximum 2,400 mg/day), diclofenac (3 times daily, not to exceed 150 mg/day), or naproxen (twice daily, not to exceed 1,000 mg/day).19 If there is any improvement, treatment can be prolonged by 1-2 weeks.
If the shoulder pain has not decreased sufficiently despite advice and analgesics, the general practitioner can give a corticosteroid injection locally. This may reduce the pain for several weeks. Keep in mind the possibility that the pain can disappear before the range of motion improves. Depending on the results of movement testing, the corticosteroid is injected either in the subacromial space or in the glenohumeral joint (intra-articular), as follows:20
For mixed clinical pictures in which it is difficult to decide which movement restriction is prominent, begin with an injection in the subacromial space.
For injection in either location: 1 ml triamcinolone acetonide, 40 mg/ml, if necessary combined with 2 ml lidocaine, 20 mg/ml. Administer the injections as follows:21
Inform the patient of the possibility of side effects, the most common being increased pain and flushes for several days.22 In the days following the injection, absolute rest or use of a sling is not necessary. Advise the patient to keep moving the arm (see under Information). If there is insufficient improvement after 2 weeks, the injection can be repeated. If there is no improvement after the second injection, further treatment with corticosteroid injections is not advisable.23
The follow-up schedule below is largely based on general principles of general practice medicine. This means that in determining the follow-up interval and frequency, the general practitioner should consider the severity of the complaints, the assessed prognosis, and the anticipated effect of treatment.
Instruct the patient to come back if:
At the follow-ups, repeat the anamnesis, and test and assess the effect of the treatment. Remind the patient that the clinical course of shoulder complaints is sometimes lengthy. If necessary, continue the use of analgesics or repeat the local corticosteroid injection.
If there are chronic complaints and indications of psychosocial stress, discuss the possible connection between them. If the patient has been absent from work, enquire about his contacts and arrangements with the medical or occupational health and safety department.
If after 6 weeks recovery is inadequate and dysfunction is present or imminent, consider referral to a physical therapist for activating, time-contingent treatment. Reconsider the diagnosis of shoulder complaints if there are persistent complaints that do not respond satisfactorily to treatment.
For patients with shoulder complaints who continue to have severe complaints and limitations despite treatment, consider consulting with or referring to another general practitioner or a specialist with specific expertise in shoulder problems. Local circumstances and personal experience in daily practice will point the way for the referral policy of the individual general practitioner.24
The boundary between moderate and severe shoulder injuries, or between those that are recent and those that are not, can usually—but not always—be drawn sharply. Severe shoulder injuries, such as complicated fractures, ruptures of the rotator cuff, and traumatic or habitual glenohumeral luxations, usually require second-line diagnosis and treatment.1 Their characteristics are acute onset associated with trauma, considerable pain (both spontaneous and during movement), an abnormal shoulder contour, loss of strength, and eventual atrophy of shoulder muscles.
Less severe trauma can usually be treated easily by the general practitioner. Examples include clavicle fracture, uncomplicated glenohumeral luxation (after spontaneous or active repositioning), and luxation or subluxation of the acromioclavicular joint.2 Shoulder complaints resulting from trauma in the distant past do not usually necessitate measures other than recommended in this guideline. In the elderly, relatively minor trauma can rupture the rotator cuff. The clinical picture is usually indistinguishable from that of other causes of shoulder complaints and the probability of post-operative healing of the rupture is small.
In the recording of diagnoses in Dutch general practice, 'shoulder complaints' is coded separately. For this diagnosis the Transition Project reported 38 contacts per 1,000 patients per year, of which 25 were initial consultations and 13 were follow-up consultations.1 The Continuous Morbidity Registration calculated an incidence of 18-21 per 1,000, and the National Study calculated 13 per 1,000 patients per year.2 3 Similar incidence figures were found in two recent trials in Dutch general practices.4 5 These numbers indicate that in a practice of 2,350 patients, the general practitioner sees 1-2 new patients with shoulder complaints every 2 weeks.
Based on data from the EPOZ study (Epidemiological Study of Cardiovascular Risk Indicators), the prevalence of shoulder complaints in the Dutch population is estimated at 100-160 per 1,000 residents.6
The clinical course of shoulder complaints was investigated in two prospective follow-up studies in patients who consulted the general practitioner for shoulder problems and were treated in the usual manner.
Winters et al. followed 101 patients for 12-18 months.1 The patients completed a questionnaire at the time of recovery and again 26 weeks later, in which they were asked about pain and whether or not they felt 'cured'. This was answered positively by 25% of the patients after 4 weeks, by 50% after 6 weeks, and by 75% after 12 weeks. At the first follow-up, at 26 weeks, 51% said they still had complaints and yet two-thirds of this group considered themselves to be cured. The average duration of complaints after the first consultation was 13 weeks. Furthermore, most patients with major shoulder complaints had already improved significantly after 2 weeks.2 At the second follow-up,12-18 months later, 41% still had complaints and 22% had again had complaints. Still, half of this group felt that they were cured. Van der Windt et al. followed 349 patients by means of a questionnaire at 1, 3, 6, and 12 months and the percentage without complaints was 23, 44, 51, and 59, respectively.3 Sixty percent of those who still had complaints at 12 months had not called on their general practitioner for help in the preceding 6 months. The median duration of complaints was 21 weeks.
Summarizing these studies:
In the literature on shoulder complaints a distinction is often made between 'intrinsic' and 'extrinsic' causes. Intrinsic causes are disorders of the glenohumeral joint (the shoulder joint per se) or of structures in the immediate area such as the subacromial bursa and the acromioclavicular joint. Extrinsic causes are disorders elsewhere in the body, such as in the neck or internal organs. These can cause 'referred pain' in the shoulder, which is simply the phenomenon of pain felt at a site distant to the location of the disorder.
It is generally assumed that disorders of the cervical or cervicothoracic spine can create not only neck pain but also radiating pain in the shoulder area. In an observational study among 101 patients with shoulder complaints, Sobel et al. were unable to determine an intrinsic cause in 20% of the cases.1 However, manual examination of the cervical and thoracic spine and the adjoining ribs did reveal abnormalities, which they called dysfunctions of the cervical and thoracic spine. They suggested that their findings concur with the observations of Stenvers & Overbeek2 and Jirout,3 4 who showed a direct relationship between movements of the upper arm and rotation of the lower cervical and upper thoracic vertebrae. A study by Norlander et al. showed that reduced mobility of the cervicothoracic spine in individuals without complaints tripled their chances of developing neck or shoulder complaints.5 Furthermore, this study showed that the mobility of the cervicothoracic spine was reduced in 84% of all patients with shoulder complaints.
Based on these data, it seems possible that reduced mobility of the cervicothoracic spine plays a role in the development of complaints in the shoulder area.
Cervical radicular syndrome resulting from irritation of a cervical spinal root is characterized by radiating pain in the shoulder area and the arm, with or without symptoms of neurological deficit. It is commonly caused by a cervical disc prolapse (usually C6-C7) and possibly also by severe forms of cervical arthrosis. The occurrence of the pain is often strongly dependent on the position and movements of the neck.1
In active rheumatoid arthritis, shoulder complaints can develop as a result of synovitis of the glenohumeral joint. Testing of movement of the shoulder joint reveals primarily restriction of exorotation.2
Bilateral pain and stiffness in the shoulder and/or pelvic girdle in older patients (usually >50 years) may indicate polymyalgia rheumatica, which is one of the rheumatic diseases. The cause is unknown, but presumably the pain is caused by inflammation of the shoulder and/or pelvic joints. The ESR is usually highly elevated. Oral treatment with a glucocorticoid (such as prednisone) usually produces spectacular improvement in just a few days, but must be continued for a long period before the condition is completely cured.3
Unexplained shoulder complaints in a patient with a history of a malignancy may indicate metastasis or spread of the malignancy to structures in the shoulder area, such as the brachial plexus, spine, or apex of the lung. Shoulder mobility is not always abnormal. Malignancy should also be considered in other patients with a progressive pattern of symptoms and similar clinical findings.4
When there is fever accompanied by general illness, an infectious processshould be suspected. It may involve the shoulder joint in the form of a purulent arthritis. Infection can also occur in the subacromial space. When an infectious disorder is suspected, refer the patient immediately to an orthopaedic surgeon.5
Disorders in visceral organs can cause 'referred pain' in the shoulder region, usually accompanied by other symptoms. Examples of such disorders include: pulmonary embolism, pleuritis, pericarditis, angina pectoris, myocardial infarction, cholecystitis, pancreatitis, adnexitis, and extrauterine pregnancy.
In a general practice study of 100 patients with shoulder complaints, De Jongh found many fewer distinguishing characteristics than there are in the Cyriax classification.1 Only the presence or absence of limitation of the range of motion differentiated between two clusters of disorders.
In another study, in 101 patients in a general practice, Sobel et al. failed to reach a diagnosis in most patients using the criteria in the first version of this NHG guideline.2 They observed that typical diagnostic criteria often applied to multiple syndromes simultaneously. In addition, movement testing of the glenohumeral joint revealed no abnormalities in 20% of their patients.
Liesdek et al. found moderate diagnostic agreement (kappa 0.31) between general practitioners and physical therapists in patients referred for physiotherapy after a diagnosis had been made on the basis of the NHG guideline.3
In a study among rheumatologists, Bamji et al. found diagnostic agreement in only 46% of the cases.4 One study, however, revealed very good reproducibility of the Cyriax method.5 Two trained and experienced physiotherapists assessed 21 painful shoulders in 19 patients in a random order, and noted the test results under blinded conditions. The authors reported a nearly perfect agreement (kappa 0.88). However, the description of the selection of the small study population was very vague
In a study by De Winter et al., two physical therapists independently studied 201 patients with shoulder complaints.6 They based their diagnoses on the first version of this NHG guideline. The agreement was moderate (kappa 0.45). They regularly classified the complaints as 'mixed clinical picture' (e.g., capsular syndrome and subacromial syndrome) or they could not classify the complaints at all. The level of agreement was negatively influenced by high pain intensity, long duration of complaints, and bilateral occurrence of the complaints. Conclusion: These studies demonstrate that the Cyriax classification has little usefulness in daily practice.
Winters et al. and De Jongh each studied approximately 100 patients who consulted the general practitioner with shoulder complaints.1 2 Based on the anamnesis and physical examination (in particular, active and passive movement testing) after cluster analysis or after cluster and factor analysis, respectively, they encountered a dichotomy in the population. One group consisted of patients with pain and restricted range of motion, and the other of patients with pain but without restricted range of motion. Furthermore, it appeared that in patients with restricted range of motion, multiple types of movement were often limited. In the group without restricted range of motion, De Jongh also encountered patients who could designate a distinct beginning and end to the pain in active abduction. This picture is consistent with the painful arc concept. Furthermore, Winters et al. encountered a small subgroup with an acute beginning, intense pain, and restricted range of motion. In a study of patients with shoulder and neck complaints, De Winter et al. found good inter-observer agreement for active and passive abduction and for passive exorotation (kappa 0.74, 0.60, and 0.55, respectively).3
Conclusion: On the basis of this data, the work group thinks that a classification system based on the presence or absence of restricted range of motion is defensible, and that this probably closely approaches the situation in general practice. The two patient groups reflect two poles on a sliding scale. This means that in practice, the general practitioner must take into account patients who are not easily categorized or who present a mixed clinical picture. Additionally, the findings in one patient can vary over time.1 For the sake of simplicity and reliability in movement testing, the work group prefers testing active and passive abduction and passive exorotation.
The subacromial space contains the subacromial bursa and the tendon of the supraspinatus muscle (which together with three other muscles, comprise the rotator cuff and grasp the humeral head), and the long tendon of the biceps muscle. Shoulder complaints presumed to have been caused by disorders of subacromial structures are described in the literature under the names subacromial syndrome, entrapment syndrome, impingement syndrome, painful arc syndrome, or PHS. According to Neer, the entrapment syndrome is the result of anatomical variations in build, strain, and repetitive microtrauma.1 The terms 'impingement' and 'entrapment' refer to the presumed trapping of anatomical structures between the broad greater tuberosity of the humeral head and the acromion during abduction. This would cause a process of degeneration of the rotator cuff, coupled with oedema, bleeding, fibrosis, and calcification. Ultimately this could cause ruptures, osteophyte formation, and spur formation. The 'typical' clinical picture would be characterized by a painful arc during abduction, while other movements of the upper arm painless. Under the Cyriax system, the diagnosis can be made more certain by palpation and 'function testing' (for such entities as insertion tendinopathy of supraspinatus and infraspinatus and subscapularis muscles or subacromial bursitis).2 Validity studies on this model are lacking, however, and there are also problems with reproducibility (see note 7). In spite of the broad application of the Cyriax method, the work group considers this system to be of no value in general practice, partly due to the complexity of the function testing and its small effect on the choice of treatment.
Ruptures of the rotator cuff would result partly from the same pathophysiological mechanisms. These may have a partly subclinical course. In 170 autopsies, Petersson et al. found 54 cases of cuff rupture which had not caused any symptoms during life.3
The 'unstable shoulder' as a cause of shoulder symptoms has received considerable interest recently, there being many publications about this syndrome, particularly in sports medicine. However, no studies of the prevalence, diagnosis, and general practice treatment of the unstable shoulder have been found. It is unclear which symptoms can be considered typical of this syndrome. In addition to pain, the patient may experience an 'insecure sensation' in the shoulder. Instability is also seen as a possible cause of subacromial problems.1 Specific tests of the stability of the glenohumeral joint have been described.1-3 The extent to which these tests contribute to a reliable diagnosis is not clear. Treatment is generally conservative, consisting of muscle strengthening, improving coordination and range of motion, and changing the exercise routine.4 5
No specific studies of the prevalence, diagnostics and treatment of non-traumatic disorders of the acromioclavicular or sternoclavicular joint were found. Sobel et al. found indications of acromioclavicular joint involvement in 13 of 101 first-line patients with shoulder complaints, but these patients also had signs of subacromial or cervicothoracic problems.6 In a general practice study, Van der Windt et al. made the diagnosis 'acromioclavicular syndrome' in 18 of 392 patients and calculated an incidence of 0.5 per 1,000 per year.7 The prevalence of acromioclavicular disorders in second-line treatment is estimated to be 10% of the cases of shoulder pain.8 9 It is assumed that the disorder is caused by strain, trauma, inflammation, or degeneration.10 In addition to pain, the symptoms include swelling, pain during palpation, and pain with some restriction during range of motion testing (specifically, passive horizontal adduction is usually mentioned).8 The disorder has been reported to occur primarily in athletes8 9 11 and persons who perform heavy physical labour.12 Although isolated disorders of the acromioclavicular joint can occur, they can also be associated with other shoulder disorders.8 Treatment is virtually always conservative. For persistent symptoms, an intra-articular injection with a corticosteroid could be given, but no systematic study of the effects of this procedure was found.
Conclusion: The work group is of the opinion that based on the presumably low incidence of unstable shoulder and non-traumatic disorders of the AC and SC joints in general practice, as well as the lack of good systematic research, it is not possible to formulate well-supported guidelines on these conditions.
The clinical picture of the painful, stiff shoulder has been described under the synonyms periarthritis humeroscapularis (PHS), frozen shoulder, adhesive capsulitis, and capsulitis since the previous century.1 It is considered to be a poorly understood inflammation and/or contracture of the glenohumeral joint capsule. The 'classical' clinical picture would be characterized by an insidious onset, without any clear cause, followed by a phase of burning or nagging pain, both at rest and during motion. Progressive restriction of mobility follows, and then gradual recovery. Reeves followed a cohort of second-line patients and found spontaneous recovery after 30 months on average (range 1-4 years). After five years, 50% of the patients still had symptoms.2 There was typically restriction during exorotation, less during abduction (the so-called 'capsular pattern'). Kessel et al. also mention the following as characteristic symptoms: pain heavier at night than during the day, more than 50% restriction of range of motion in all directions, pain during passive movements, and exorotation more restricted (< 20o) than abduction (< 45o).3
Codman considered the rupture of a calcified deposit from the cuff to the subacromial bursa above it to be the most important cause of acute bursitis, resulting in an acute, very painful, sterile inflammatory process.1 As classical symptoms, he described quite intense pain arising suddenly, disturbed nightly sleep, and restriction of movement, primarily during abduction and to a lesser extent during exorotation. Codman's hypothesis of the explanation for this clinical picture has been adopted by many others, but never confirmed by good research.
For the motivation for the choice of tests, see note 8. Textbook descriptions of movement testing of the shoulder are not uniform.1 2 They also do not use a uniform terminology. For instance, abduction of the arm is sometimes termed elevation. The work group has decided on a pragmatic, accessible instruction, but realizes that all roads lead to Rome.
Movement testing of the shoulder is performed with the patient sitting or standing. When performing passive tests, ask the patient to relax as much as possible. Always compare with the other side.
De Wolf AN. Onderzoek van het bewegingsapparaat [Study of the locomotor apparatus]. Houten: Bohn Stafleu Van Loghum, 1990.
The Transition Project found that general practitioners request x-rays in approximately 10% of their cases of shoulder complaints.1 There has been no valid study of the value of x-rays in diagnosis of non-traumatic shoulder complaints in general practice. This also applies to magnetic resonance imaging (MRI), computer tomography (CT), and ultrasonography. There have been studies in second-line practice, in patients with acute and subacute post-traumatic shoulder complaints.2-4 In patients without complaints, Liou et al. detected abnormalities by MRI in the distal tendon of the supraspinal muscle (94%), in the subacromial space (95%), and in the acromioclavicular joint (48%).5
Conclusion: Too little is known to reach a conclusion about the contribution of imaging in examination in non-traumatic shoulder complaints in general practice. The work group is of the opinion that additional examinations will generally have no real effect on the diagnosis or management of shoulder complaints, except when the clinical course is abnormal or serious disease is suspected.
Several studies of differing quality have been aimed at determining which characteristics are associated with a positive or negative clinical course in shoulder complaints. The results vary and should be interpreted with caution.
Rapid recovery appears to be associated with acute onset of the complaints1 5 and a short interval between onset and the initial consultation,1 4 5 6 8 as well as with complaints caused by unusual activities (such as painting the ceiling),1 hobbies or sports,8 or slight trauma.1 The clinical course appears to be less favourable in patients who have had the complaints before,6 who have severe shoulder complaints,1 6 and in whom passive abduction is greatly restricted.6 In addition, symptoms which are on the dominant side8 9 and are associated with neck pain1 are associated with less rapid recovery. It is possible that patients with a capsular disorder have a poorer prognosis if they are elderly.3 Prolonged absence from work and irregular use of medications seem to promote the persistence of complaints.2 It also appears likely that psychosocial factors may negatively influence the development and continuation of complaints.10 11 A prospective study showed that people with depression are more likely to develop chronic pain and that the reverse is also true.11
The work group's recommendation of a time-contingent approach to shoulder complaints is based on the following considerations. In most patients, pain in the musculo-skeletal system mainly leads to limitations in normal daily activities and to work absenteeism during the acute phase. In some patients, pain-related illness behaviour contributes to the continuation of these limitations, even after the acute phase.3 8 9 Because they are afraid that pain and movement will cause repetition of the injury, they develop pain- and movement-avoidance behaviour. A pain-related approach—advice to avoid movements, activities, and work until the pain has lessened or disappeared—could strengthen the avoidance behaviour. Confirmation of avoidance behaviour by family, friends, or others who help the patient may also contribute to the continuation of the pain symptoms and the restrictions associated with them. In time, avoidance behaviour could result in loss of physical conditioning, development of depression, or a decrease in pain tolerance.3 8 9
A time-contingent approach to pain symptoms is aimed at changing the avoidance behaviour. The patient is advised to move and to increase normal activities and routines on a daily or weekly step-by-step basis, in spite of the pain. For such pain symptoms as vague abdominal pain,1 pain in the locomotor apparatus,4 back pain,2 and headache,6 as well as for somatization,5 a time-contingent approach appears to lessen the limitation of activities and occupations, reduces medical consumption, and shortens absence from work. Furthermore, a time-contingent approach appears to be effective for pain symptoms in the upper extremities.7
All of this does not alter the fact that the feasibility and the effect of the time-contingent versus pain-related approach in general practice has never been studied systematically. Studies are still needed to determine the most effective approach for prevention or treatment of chronic shoulder complaints.
Conclusion: For pragmatic reasons, the work group prefers a time-contingent approach to shoulder complaints, with the aim of preventing pain and movement-avoidance behaviour.
Many studies of the effect of various forms of physical therapy (including specific exercises, application of heat or cold, or liniments) for disorders of the shoulder reveal serious shortcomings in design and implementation.1 2 The valid studies available have shown that technical applications, such as transcutaneous electrical nerve stimulation (TENS), ultrasound, and interference current had no effect on the clinical course of acute or chronic shoulder complaints.3 4 No valid studies have shown that other forms of physical therapy (including specific exercises, application of heat or cold, or liniments) in the acute phase of shoulder complaints reduce the duration of symptoms or the number of recurrences. There are, however, indications that remedial therapy can hasten somewhat the recovery from persistent shoulder complaints .5
Conclusion: Due to the lack of sufficient good research, no statement can be made about the effectiveness of physical therapeutic forms of treating shoulder complaints, with the exception of technical applications. Since the natural clinical course in many patients is benign, and since the general practitioner can treat many patients with shoulder complaints during the acute phase, the work group recommends not referring for exercise therapy in the acute phase, i.e., for approximately the first 6 weeks. If there is insufficient improvement and there are restrictions in the patient's daily activities after this phase, the general practitioner can consider referral. In all the phases of shoulder complaints, treatment with technical applications is not advised.
In four randomized trials the effects of NSAIDs were compared with those of placebo in patients with shoulder complaints.1-4 In three of these studies there was a beneficial effect, mainly during the first 2 weeks of treatment.1-3 In many other studies, various NSAIDs were compared with each other.5 6 Based on these studies, there appears to be no reason to prefer a specific NSAID, since both effectiveness and frequency of side effects were similar among all of them. The adverse effects of NSAIDs include gastrointestinal ulcers, renal dysfunction, hypersensitivity reactions, and heart failure.7 Based on four patient-control studies, the Medications bulletin concluded that the risk of gastrointestinal bleeding from use of seven frequently-used NSAIDs differs significantly from non-usage, and that the risk per NSAID varies considerably.8 The risk of bleeding appeared to be least elevated for ibuprofen, followed by diclofenac and naproxen, and most elevated for piroxicam and azapropazone. Indomethacin and ketoprofen were rated in the middle. Furthermore, the risk increased in proportion to the daily dosage, the age of the patient, and the duration of use.
There have been no studies comparing NSAIDs with paracetamol for treatment of shoulder complaints, and so it is not clear whether paracetamol is as effective, while avoiding the higher risk of adverse effects with NSAIDs. In patients with arthrosis of the knee, the effects of paracetamol and ibuprofen proved to be similar.9
Conclusion: Based on the high frequency and severity of the adverse effects of NSAIDs, the work group recommends starting treatment with paracetamol and changing to ibuprofen, diclofenac, or naproxen only if paracetamol is ineffective.
Of the local injections that are possible in patients with shoulder complaints, the subacromial and the glenohumeral injections of corticosteroid have been studied most extensively. Two recent articles provide an overview of the results of studies on the efficacy of corticosteroid injections for shoulder complaints.1 2 Both articles reach the conclusion that the methodological quality of most studies leaves something to be desired. The most important shortcomings are the lack of comparability of co-interventions and insufficient blinding.2
Most studies have revealed no difference between treatment with corticosteroid injections and a placebo, or between injections and other common interventions for shoulder pain. However, two studies of relatively good methodological quality have shown beneficial short-term results (2 to 4 weeks) from corticosteroid injections when compared with lidocaine.3 4 Both studies involved a subacromial injection of triamcinolone acetonide (40 and 80 mg, respectively) in combination with a local anaesthetic. Similarly, a recent study (not included in the review articles) revealed beneficial short-term results from a subacromial injection of 40 mg triamcinolone acetonide.5 The difference in the rate of recovery between injection of triamcinolone and injection of lidocaine varied from 20 to 70% in these studies (numbers needed to treat 1.5 to 5). In a randomized study of patients with a painful, stiff shoulder, the recovery was shown to be better with 40 mg than with 10 mg triamcinolone.8
Until recently, intervention studies were carried out predominantly in the patient populations of rheumatologists, orthopaedists, or rehabilitation specialists. It is debatable whether the results of these studies can be generalized to patients with shoulder complaints in general practice.1
Two recent randomized intervention studies in general practices in the Netherlands found corticosteroid injections to be beneficial when compared with physical therapy.6 7 In the study by Winters et al., patients with 'synovial syndrome' (disorders of the glenohumeral synovial joint, subacromial structures, AC joint, or a combination thereof) were treated with at least two local injections per treatment.6 No more than three treatments were given in approximately 4 weeks. In the study by Van der Windt et al., patients with shoulder pain and a mainly passive restriction of exorotation ('capsular syndrome') were treated with a maximum of three injections in the glenohumeral joint in 6 weeks.7 In both studies there were short-term benefits. There was 55% recovery after the injections and 31% after physiotherapy (numbers needed to treat 1.8 and 3.2, respectively). There difference between the two intervention groups was no longer so large at a 6-month follow-up and the earlier difference was shown to be mainly the result of the more rapid recovery following corticosteroid injections. There was no difference between the treatment groups at a follow-up after 1.5 years.9
Conclusion: Based upon the results of the above studies, the work group concludes that if the effect of providing information and advice, a policy of watchful waiting, and/or analgesics is not enough, a corticosteroid can be injected locally. Lessening of pain is possible for up to approximately 4 weeks. More research with a longer follow-up is needed to clarify the long-term results.
Administering the two injections recommended in this guideline is not difficult after some training, but before attempting them in practice, you should consult a manual,1 ask advice of an experienced colleague, or take a refresher course. Studies in which placement of the shoulder injections was checked by x-rays revealed that inaccurate placement does occur, even among trained physicians.2 3 Recent studies indicate that correct placement yields better results.3 4 Although incorrect placement of local corticosteroid injections can also occur in general practice, in the two intervention studies in Dutch general practices mentioned in the previous footnote, relatively positive recovery percentages were reported after injection treatment.
Various long-acting corticosteroid preparations are available for local injection.5 The work group has chosen triamcinolone acetonide, because there is already extensive experience with it and it has been used in the most successful trials. Although there are no systematic studies on the specific effect of lidocaine, it is often used, with or without a corticosteroid. For example, its analgesic effect is used as a diagnostic tool in the subacromial space, for verification of the diagnosis (the so-called 'impingement test'6). Lidocaine is also thought to have a therapeutic effect. Both hypotheses lack proof. In the majority of the trials discussed above, a corticosteroid was used in combination with lidocaine (usually 2 ml, sometimes more).
Conclusion: Based on this information, the work group can neither recommend nor advise against the use of lidocaine.
There are very few publications concerning the adverse short-term or long-term local or systemic side effects of corticosteroid injections. Pain following the injection, and lasting several days, and facial flushes are mentioned most frequently.1-4 There is incidental mention of menstrual disorders and postmenopausal bleeding.2 3 The mechanism for these side effects is unclear. Patients with diabetes mellitus must take into account a temporary increase in blood sugar levels.4 Other presumed side effects are probably rare: redness at the site of the injection, atrophy of the skin or subcutis, hyperpigmentation or hypopigmentation, sterile abscess, crystal synovitis, subcutaneous necrosis, urticaria, bacterial arthritis, arthrosis, acute synovitis, and tendon ruptures.4 5 In a four-year follow-up study of 53 patients who were given 1 to 34(!) injections in various joints, Keagy and Keim found no indications of harmful side effects.6 They concluded that there were no objections against repeated corticosteroid injections.
Due to the lack of systematic research, exact guidelines for the preferred interval between two injections cannot be given. The recommendations vary from 2 to 12 weeks.1 2
The recommended maximum number of injections per year also varies. For practical reasons, the work group has decided on an interval of 2 weeks. There is no objection to giving multiple injections during a single complaint episode, but if there has been no improvement at all after two injections, giving additional injections does not seem worthwhile.
Data from the Transition Project show that approximately 5% of patient in the categories involving shoulder complaints are referred to a specialist.1 This is consistent with the referral statistics in the United States, where about 95% of patients with acute shoulder complaints are treated by general practitioners.2
Theoretically, the specialists to whom patients can be referred are orthopaedic surgeons, rehabilitation physicians, and sports physicians. There are no data on how referral contributes to the recovery. Well-designed randomized studies comparing the effect of operative treatment for non-traumatic shoulder problems with conservative measures or placebo are uncommon. In a randomized study, Brox et al. compared the effect of surgery, 3-6 months of exercise therapy, and 6 weeks of placebo-laser treatment in 125 patients with a subacromial syndrome that had lasted 3 months or longer.3 Assessment 6 months later showed that the placebo group had improved significantly less than the two other intervention groups, while surgery was somewhat more effective than the exercise therapy. Morrison et al. retrospectively studied the results of a non-operative approach in 616 referred patients with subacromial problems.4 The patients were given exercise therapy for the shoulder musculature and were followed for 27 months on average. The results were good in two-thirds of the patients but 28% still eventually required surgery.
The work group's conclusion is that for some shoulder complaints, a lengthy clinical course and frequent recurrences can be expected. Restraint in offering surgery appears to be appropriate as long as the results have not been proved in well-designed research. This means that even after referral, in the majority of cases, initially conservative forms of treatment should be preferred to invasive procedures.
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