Informing patients 2: Shoulder Pain – Benefits and Risks and Treatment Alternatives

ARCHIVED POST N.B. This post is based on the 2012 Osteopathic Practice Standards and therefore may not reflect current legislation or current Mint procedures.

An information resource for practitioners

The law on consent require health practitioners to inform patients of the benefits and risks of treatment and alternative treatments.  This article is part of a series to equip practitioners to inform their patients.  It is to be noted that it is difficult to find information on benefits and risks of treatments so please feel free to provide feedback so we can develop this resource.

This list is a generalised list to use a resource and needs to be applied using your osteopathic expertise, based on the patient’s condition, presentation, preferences and understanding.

N.B. this information is written for practitioners with medical knowledge, if you are suffering with shoulder pain please seek advice from a health practitioner.

Shoulder Pain

Shoulder pain includes diagnoses of instability, rotator cuff dysfunction, dislocation, OA of the A/C or G/H joints, impingement and frozen shoulder.

Pain may be referred from the neck, diaphragm, or heart.

Time, education and posture improvement

Reassurance symptoms will resolve – tissues heal in known time frames – muscles, ligament etc.  Advice on work-place posture, overhead activities, psychosocial factors.  Realistic expectations, especially for frozen shoulder recovery time.

Benefits: low-cost option, possibility of full improvement, empowers patient

Risks: Underlying contributing factors may not be resolved increasing likelihood of recurrence, may take a few weeks.  Yellow flags may be barriers to improvement

Manual Therapy

Ultrasound, massage, mobilisation, stretching and cuff-strengthening exercises.  Taping may be helpful in early management of a/c joint sprains.

Benefits: Helps improve range of motion and reduce muscle tension, may help reduce likelihood of recurrence of symptoms.  Faster improvement than time and education alone.

Risks: May have increased tenderness after hands-on treatment for 24-48 hours, improvement may take a few sessions (1 in 2).  Small risk of nerve compression causing temporary tingling and numbness (1 in 100).  Very low risk of long-term nerve damage.

Exercise

Good evidence effective for reducing pain in impingement syndrome.  Limited evidence for mixed shoulder disorders and rotator cuff disorder.  Recommended daily ROM exercises, strengthening three times per week and heat or cold.  Vigorous stretching in early phase frozen shoulder will exacerbate pain.

Benefits: Enables patient to take active role in treatment, shown to improve symptoms in some cases

Risks: Potential for injury if does exercise incorrectly, exacerbation of symptoms

Psychological intervention – CBT

Pain catastrophizing – repetitive negative thoughts during actual or anticipated pain – is a major determinant of negative outcomes with chronic pain.  Work-related problems are a common factor in shoulder pain.

Benefits: Addresses psychological aspect of pain.  Educates and provides long-term management strategies

Risks:  Dis-engagement, ineffectiveness

Acupuncture

May have short-term benefits

Benefits: Pain reduction

Risks: Infection, pneumothorax, headache, fatigue, bruising

Corticosteroid injection

May increase benefits of manual therapy in rotator cuff disorder and adhesive capsulitis.    Most appropriate if limited function because of pain or making little progress after several weeks of physical therapy.  Advisable early on in frozen shoulder.

Contraindications: Not if previously had minimal or no benefit of injection from experienced practitioner

Previously had three injection in the same shoulder in the course of a year

Rotator cuff tear suspected

Infection, sensitivity to local anaesthetic, adjacent osteomyelitis.

Benefits: Pain reduction

Risks: infection, tendon rupture, hyperglycaemia in people with diabetes, local tissue atrophy, flushing, menstrual disorders in women

Analgesia

No evidence of benefit for most shoulder conditions but may be given based on clinical judgement.  Limited benefit for acute tendonitis and bursitis.

Medication Benefits Risks Additional Information
Paracetamol No gastrointestinal toxicity, well-tolerated   More effective taken regularly, rather than as required
NSAIDs – Ibuprofen

(naproxen, diclofenac)

Anti-inflammatory Dyspepsia

Gastrointestinal bleeding

Cardiovascular and renal adverse effects

Exacerbate asthma

Not effective for neuropathic pain

Gastroprotection may be required

Combined analgesics Combined beneficial effects

*Reduces number of tablets to be taken.

Risk of overdose and renal toxicity *Now recommended to be taken as separate tablets apart from chronic stable pain, although limited evidence
Codeine (weak opioid), dihydrocodeine, tramadol Mild-moderate pain treatment, tramadol may be effective with neuropathic pain Constipation, aggravate asthma, risk of dependence, drowsiness, renal side-effects

Tramadol – rarely – convulsions, psychiatric reactions.

Sedative effects can add to psychological factors and exacerbate feelings of helplessness and depression.

 

Amitryptiline   Drowsiness  
Gabapentin or pregabalin Chronic neuropathic pain Dizziness, headache, diarrhoea, confusion, mood effects Side effects are very common.
Topical NSAID Good for single regional pain relief    

 

Surgery

Surgical assessment required if a/c dislocation

Rotator Cuff Repair 15-20% don’t fully heal or re-tear

Arthroscopic stabilisation 5-10% risk of recurrent dislocation or instability.  Recommended in people under 30 years of age with instability.

Shoulder replacement 1 in 20 over 8 years loosen without infection, may need further surgery or replacement again

Arthroscopy – minimally invasive so heals quickly, minimal blood loss – less bruising and pain

Risks – stiffness, weakness, nerve damage, infection

Manipulation under anaesthetic – for frozen shoulder but still needs mobilisation and intensive manual therapy.  Fractured humerus is complication.

Arthroscopic capsular release

Plasma rich platelet therapy – Increases platelet concentration at site so adding more growth factors encouraging repair at site more rapidly.

No risks or strain associated with surgery 80-85% success with 2-3 treatments, risks – infection and minor pain

Stem cell therapy – Uses body’s own stem cells to speed up healing

quick procedure, less invasive than surgery, shorter recovery.  Results take 1-2 months and up to 6 months

Risks – infection at site of infection and infection generally as reduces white blood cells.

Asymptomatic MRI and U/S findings

Asymptomatic findings are common around the shoulder.  This data can be useful for informing patients about expectations from symptoms:

Age of patient % Prevalence of asymptomatic rotator cuff tear
  Templehof et al, 1999 Hiroshi et al, 2013
20-40s   0
50s 13 11
60s 20 15
70s 31 26
80s 51 37

 

51 ultrasound images of asymptomatic shoulders age 40-70 (Girish et al, 2011)

78% subacromial-subdeltoid bursal thickening

65% acromioclavicular joint osteoarthritis

39% supraspinatus tendinosis

25% subscapularis tendinosis

22% Partial thickness tear supraspinatus tendon

14% Posterior glenoid labral abnormality

Asymptomatic shoulder abnormalities were found in 96% of the subjects.

 

References

NICE Clinical Knowledge Summaries, available at: http://cks.nice.org.uk/#?char=A

www.patient.info

www.Shoulderdoc.co.uk

Templehof, S.; Rupp, S.; Seil, R. (1999) Age-related prevalence of rotator cuff tears in asymptomatic shoulders.  Journal of Shoulder and Elbow Surgery Jul-Aug;8(4):296-9.

Hiroshi, M.; Nobuyuki, Y.; Hidekazu, A.; Masashi, F.; Nobutoshi, S.; Kazuma K.; Hiroaki, K.; Eiji, I. (2013) Prevalence of Symptomatic and Asymptomatic Rotator Cuff tears in the general population; from mass screening one village. Journal of Orthopaedics  Mar; 10(1): 8–12.

Girish, G.; Lobo, L.G.; Joacobsen, J.A.; Morag, Y., Miller, B., Jamadar, D.A. (2011) Ultrasound of the shoulder: Asymptomatic findings in men.  American Journal of Roentgenol Oct;197(4):W713-9.

 

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