International Journal of Osteopathic Medicine 42 (2021) 11–19

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International Journal of Osteopathic Medicine

journal homepage: www.elsevier.com/locate/ijosm

Epidemiology, common diagnoses, treatments and prognosis of shoulder

pain: A narrative review
Christopher Hodgetts *, Bruce Walker
College of Science, Health, Engineering and Education, 90 South Street, Murdoch University, Perth, Western Australia, Australia

A R T I C L E I N F O A B S T R A C T

Keywords: Background: Shoulder pain is lacking a contemporary comprehensive overview article that summarizes key as­
Shoulder pain pects of the presentation.
Epidemiology Objective: To provide a contemporary summary of the literature on shoulder pain, including: epidemiology, cost-
Prognosis
of-illness, common diagnoses, common treatments, and prognosis.
Pain management
Rotator cuff
Methods: PubMed, CINAHL and Google Scholar were searched using search terms including: shoulder pain,
prevalence, epidemiology, diagnosis, risk factors, prognosis, surgery and conservative care. Information from the
highest level of evidence available was synthesized and summarized.
Results: Shoulder pain is the third most common musculoskeletal complaint and several cost of illness studies
suggest it is of significance. Common diagnoses can be categorised on the anatomic region such as ‘intra-artic­
ular’, ‘anterior shoulder’ and ‘subacromial’. Despite surgery rates increasing in some areas, multiple systematic
reviews suggest there is no difference in pain and disability outcomes between surgical interventions and con­
servative approaches. Several studies have revealed that only 50% of all new cases of shoulder pain completely
recovery after six months, and 60% after 12 months.
Conclusion: Shoulder pain is a relatively common musculoskeletal complaint and costs associated appear
reasonably high. Practitioners need to be aware of overlap with diagnostic terms, the equivalence of available
interventions, and that shoulder pain conditions may not be self-limiting.

Implications for practice
• This review provides clinicians with a contemporary overview of
shoulder pain.
• Clarity is provided regarding diagnostic labelling for shoulder pain.
• Conservative management should be the primary approach for sub­
acromial pain syndrome and rotator cuff tears.
• Shoulder pain is not self-limiting in nature and negative prognostic
factors include: longer duration of symptoms, high pain intensity and
disability, the presence of concomitant symptoms and range of mo­
tion loss.
Background
Shoulder pain can be defined as pain in “the part of the body in
humans where the arms connect to the trunk. The shoulder includes five
joints; the acromioclavicular joint (ACJ), coracoclavicular joint (CCJ),
glenohumeral joint (GHJ), scapulothoracic joint (STJ), and
sternoclavicular joint (SCJ)” [1]. The surrounding soft tissue can be
included as defined by Murphy et al. and illustrated by the body diagram
Fig. 1 [2–4].
A preliminary literature review of shoulder pain identified a lack of
contemporary overview articles. Narrative reviews are of value to health
professionals, providing a concise summary of contemporary literature
on a broad topic such as pain presentation [5]. Clinicians require in­
formation on how common the presentation is and its global impact
regarding cost of illness and burden of care. Furthermore, they require
an understanding regarding contemporary assessment procedures, and
the effectiveness of management strategies for shoulder pain.
Understanding the prognosis and prognostics factors for shoulder
pain presentations is important for clinicians when selecting potential
treatment options and providing patient education.
This review aims to provide a contemporary summary of the litera­
ture on shoulder pain. The objectives are to provide a summary of
shoulder pain research investigating:

* Corresponding author.
E-mail addresses: c.hodgetts@murdoch.edu.au (C. Hodgetts), bruce.walker@murdoch.edu.au (B. Walker).

https://doi.org/10.1016/j.ijosm.2021.10.006
Received 26 October 2020; Received in revised form 12 September 2021; Accepted 14 October 2021
Available online 21 October 2021
1746-0689/© 2021 Elsevier Ltd. All rights reserved.

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C. Hodgetts and B. Walker
• Epidemiology of shoulder pain, including the prevalence, incidence,
cost and burden.
• Common musculoskeletal shoulder diagnoses.
• Assessment procedures used in evaluating a patient.
• Effectiveness of treatment options.
• Prognosis, prognostic factors and trajectory of shoulder pain.
Methods
Design
This narrative review was completed applying the Scale for the
Assessment of Narrative Review Articles (SANRA) (appendix 1) [6].
Search strategies and study selection
PubMed, CINAHL and Google Scholar were searched from inception
to July of 2020, combining search terms in a modified ‘PICO’ framework
[7].
• Population: shoulder pain.
• Intervention: surgery.
• Comparison: conservative care.
• Outcome: prevalence, epidemiology, diagnosis, risk
prognosis.
Articles were also sought from the reference lists of key papers. Ar­
ticles included those with a Definition of shoulder pain, “pain in the
shoulder” or “self-reported shoulder pain”. The inclusion criteria were:
all types of articles, though clinical guidelines, systematic reviews, and
randomized controlled trials were favoured when available. Exclusion
criteria were: articles where full text was not available and articles that
were not published in English. Data were synthesized and summarized
into epidemiology and cost, diagnosis, assessment, treatment and
prognosis. As this was a narrative review, we did not conduct a risk of
bias analysis of the selected studies [8].
Fig. 1. A body diagram illustrating the location of shoulder pain [2]. Reprinted from Journal of Manipulative and Physiological Therapeutics, 33/9, Mario Pribicevic,
Henry Pollard, Rod Bonello, Katie de Luca, A Systematic Review of Manipulative Therapy for the Treatment of Shoulder Pain, Pages 679–689, Copyright (2010), with
permission from Elsevier.
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International Journal of Osteopathic Medicine 42 (2021) 11–19
Results
Prevalence and incidence
The prevalence estimates of shoulder pain have wide ranges, with
point prevalence estimates ranging from 7 to 26% and 7–67% for life­
time prevalence [9]. Other period prevalence estimates have been re­
ported between 17-31% and 4.7–46.7% for 1-month and 1-year periods
respectively [9]. The ranges within specific time frames have a large
amount of overlap and reflect the heterogeneity of studies in areas such
as shoulder pain Definition, populations, sample size and methodolog­
ical quality.
With respect to incidence, Luime et al. included one study with a
longitudinal design investigating the (annual) incidence of shoulder
pain [9]. However, the authors did not publish confidence intervals for
the incidence estimates, and therefore their statistical significance is
unknown. The annual incidence of shoulder pain in the general popu­
lation is unknown. A study from the Netherlands did investigate the
number of patients presenting with a shoulder disorder to general
practice [10]. The authors reported a cumulative incidence of
11.2/1000 patients/years. The low rates could indicate that there are
many cases that do not present to general practitioners, or perhaps it
reflects the chronic nature of shoulder pain. However, self-reported
shoulder pain is considered the third most common cause of a muscu­
factors, loskeletal pain presentation in primary care in the United Kingdom
(UK), with close to 1% of adults consulting a general practitioner with a
new episode of shoulder pain annually [11].
Shoulder problems are sometimes severe enough to result in hospi­
talization, e.g. in Australia in 2015–2016 there were 35,000 hospital­
isations for shoulder pain [12]. The most common diagnoses were:
rotator cuff syndrome (RCS) (21,239), impingement of shoulder (7579),
adhesive capsulitis (2,059), bursitis (1327), calcific tendinitis of shoul­
der (661) and bicipital tendinitis (234) [13]. In the same period the most
common shoulder surgical procedures were: arthroscopic stabilization,
total arthroplasty rotator cuff repair coupled with decompression of the
subacromial space and RCS repair in isolation [14].
12
C. Hodgetts and B. Walker
Cost/burden
Although there are few studies on the economic burden of shoulder
pain, the cost is likely sizable. For example, in Australian public hospi­
tals the average cost for the major diagnostic category of “diseases and
disorders of the musculoskeletal system and connective tissue” was
$8,121 [12]. If shoulder lesions and injuries are combined, the cost over
the 2015–2016 period is estimated at $640 million AUD [13].
Few researchers appear to have studied the economic aspect of
shoulder problems in more detail, but one study reported that physio­
therapy consultations were responsible for 60% of the health care costs
on this condition [15]. General practitioner costs were the next highest
but were less than half the amount spent on physiotherapy [15]. Sur­
geries to repair rotator cuff tears are both common and costly. A report
based on data collected in national health-care surveys in the United
States, stated that at least 250,000 repairs were performed annually,
costing close to USD 3 billion [16].
As for the consequences, some research suggests that RCS is the most
common upper limb diagnosis to result in time away from work, ac­
counting for one third of leave absences [17]. On an individual level,
shoulder pain has high levels of pain and disability, and also associated
poor general health status [18].
Diagnosis
Diagnostic confusion
Many overlapping diagnostic labels are applied to the presentation of
shoulder pain causing confusion. This is likely due to contemporary
terms replacing those previously used and a large degree of overlap with
multiple diagnoses. Shoulder pain diagnoses have been divided into
three key areas based on anatomic regions: intra-articular, anterior
shoulder, and subacromial. The following section summarizes the
literature based on common conditions within these anatomic regions.
Intra-articular conditions
Adhesive capsulitis (frozen shoulder). Definition: Although there is no
clear definition for frozen shoulder, it can be considered to involve
shoulder pain with stiffness of unknown origin [19]. The condition may
be idiopathic or secondary to trauma, surgery, diabetes, or thyroid
disease and is characterised by a spontaneous onset of shoulder pain,
with progressive loss of movement [19].
Pathology: The pathological process of frozen shoulder appears to
include chronic synovial inflammation and capsular fibrosis of the gle­
nohumeral joint. However, the exact pathogenesis and pathological
processes are unknown [19–22].
Diagnosis: The diagnosis of frozen shoulder is based on clinical
findings, but there is currently no universally accepted criteria [23].
Clinical findings include a gradual onset of pain and stiffness, a global
loss of both active and passive range of motion, and pain at the end of the
range of motion [23]. However, initially it may be difficult to differen­
tiate frozen shoulder from other painful shoulder conditions, because
stiffness may not be present and imaging findings on X-ray and Ultra­
sound are unrewarding [19,24].
Incidence: Three-year incidence of frozen shoulder in a large pro­
spective longitudinal study was shown to be less than 1% [25] and it is
more prevalent in those between the ages of 40 and 65, females and
individuals who have had presented the condition previously in the
opposite shoulder [26].
Prognosis: The condition has long been considered self-limiting over
1–3 years, with inflammatory/stiffening, frozen and recovery phases.
These three phases were first proposed by Reeves [27] and further
expanded to four phases by Neviaser and Neviaser, when the first phase
was broken into painful and stiffening stages [28]. The natural history
theory for frozen shoulder has been supported by a systematic review
13
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International Journal of Osteopathic Medicine 42 (2021) 11–19
that included seven studies [29]. However, a recent systematic review
does not support the theory of complete recovery without intervention
[30]. Approximately 20–50% of patients have symptoms that persist
beyond the 3 years suggesting conservative or surgical management
strategies may be necessary [31].
Osteoarthritis. Definition: Osteoarthritis (OA) of the GHJ displays the
hallmark x-ray signs of articular cartilage/sub-chondral bone degener­
ation and joint space narrowing with significant levels of pain, and
limitation in both range of motion and function [32].
Prevalence/Incidence: OA of the GHJ is present in approximately
20% of those in the elderly population [32].
Pathology: As with other variations of OA, this can result from pri­
mary or secondary processes. Primary OA of the shoulder is the third
most common site behind hip and knee sites. Secondary OA can occur
after trauma, surgery, inflammatory conditions, or atraumatic osteo­
necrosis [33].
Diagnosis: A combination of clinical and radiographic findings are
used to form a diagnosis of GHJ OA. Patients will commonly describe
vague and diffuse chronic pain, which may have been insidious in onset
or after trauma, surgery or other conditions as mentioned above. The
symptoms are often worse in the morning, easily affected by the
weather, and increase with use of the GHJ [34].
Physical examination reveals diminished active and passive ranges of
motion, and often movement crepitus. If joint palpation or passive range
of motion do not recreate the pain, then conditions such as bursitis,
rotator cuff disease, or biceps tendinopathy are more likely [35].
Anterior shoulder conditions
Long head of biceps pathology. Anatomy: The long head of the biceps
tendon attaches intra-articularly to the anterior and posterior aspect of
the superior labrum. The tendon is supported in the inter-tubercular
sulcus (or bicipital groove) by the transverse humeral ligament, cor­
acohumeral ligament, superior glenohumeral ligament, supraspinatus,
and subscapularis. The subscapularis provides the anterior pillar at the
most medial edge of the groove, and the supraspinatus provides the
posterior pillar at the lateral edge.
Pathology: Although isolated biceps pathology can occur, it is more
often related to rotator cuff disease or labrum injuries [36]. Chen et al.
defined six categories of long head of biceps tendon pathology: tendi­
nitis (type I), subluxation (Type II), dislocations (Type III, partial tears
(Type IV), complete tears (Type V), and superior labrum
anterior-posterior (SLAP) lesions (Type VI) [37,38]. This was the first
time that SLAP lesions were classified as a type of biceps pathology and
it is important to note that SLAP lesions have a separate classification
system described below.
Diagnosis: Patients often present with anterior shoulder pain, which
palpation of the biceps tendon recreates. The combination of pain on
palpation with O’Brien’s compression test and the throwers test has
been shown to useful in diagnosis with a sensitivity of 73–98%, a
specificity of 46–79%, and high inter-rater reliability (Kappa 0.7–0.8)
[39]. Speed and Yergason tests demonstrated a moderately-high sensi­
tivity, but a high specificity of 86.7 and 97.9% respectively [39]. The
uppercut test has also shown diagnostic strength with a sensitivity of
73%, a specificity of 78%, a positive predictive value of 0.63 and a
negative predictive value of 0.85 [40].
Labrum injury. Anatomy: The glenoid labrum acts to increase the con­
tact area between the head of the humerus and the glenoid fossa, con­
tributes to the “viscoelastic piston” effect that maintains a negative
pressure within the joint and also serves as an attachment site for gle­
nohumeral ligaments and the long head of the biceps [41].
Pathology: The structure can be injured through repetitive overhead
movements, or via trauma such as a fall on an outstretched hand
C. Hodgetts and B. Walker
(FOOSH) injury [42]. Researchers have not reached a consensus on the
biomechanical reason for labrum injuries, but the literature supports the
theory that athletes involved in repetitive overhead activities such as
tennis or baseball players can have greater maximal external rotation,
and less internal rotation leading to increased shearing forces on the
biceps anchor and superior labral ligament attachment sites. This is
likely to contribute to the subsequent stress placed on the labrum and
ultimately injury [42]. The labrum can be injured in any of its sections,
though 80–90% of lesions will be on the superior aspect [41]. Snyder
et al. provided the initial four type classification of SLAP lesions and
Maffet et al. expanded it to include further six types [43].
Diagnosis: A SLAP lesion is diagnosed with both clinical and imaging
findings. The lesion occurs more commonly in the dominant arm of
young over-head athletes who report anterior shoulder pain and loss of
range of motion [42]. These symptoms affect the athlete’s ability to
throw or serve. Unfortunately, orthopaedic tests are not clinically useful
to diagnose this condition [44,45]. Magnetic resonance arthrography
remains the gold standard for diagnosing SLAP lesions with a sensitivity
of 80% and specificity of 90% [46].
Subacromial conditions
Anatomy of subacromial space. The subacromial space exists between the
coracoacromial roof (anterior acromion and coracoacromial ligament)
and the humeral head [47]. The section of the humeral head that is
within the space includes the greater and lesser tubercles and is covered
by the rotator cuff tendons and the biceps tendon. These surfaces are
separated by the subacromial-subdeltoid bursa which is a potential
space that exists between serosal surfaces of the deep and superficial
structures [47]. Although the bursa is often described as two separate
structures (subacromial and subdeltoid), they are one [48]. The sub­
acromial bursa is considered the section, which is not palpable from the
surface and exists between the serosal surfaces on the cuff and the un­
dersurface of the acromial arch, and the subdeltoid bursa is the palpable
section that exists between the cuff and the undersurface of the deltoid
muscle [47].
Rotator cuff disease. Definition: The definition of rotator cuff disease
(RCD) is problematic as there are numerous labels that describe the
same presentation including rotator cuff degenerative disease (RCDD),
RCD, rotator cuff tendinopathy, rotator cuff injury, rotator cuff lesion,
and rotator cuff syndrome. For this review, the term RCD will be used for
atraumatic presentations, and rotator cuff injury when describing
traumatic or acute lesions.
The rotator cuff (RC) is a grouping of tendons that surround and
attach to the head of the humerus [49]. The muscles that contribute to
the cuff are the supraspinatus, infraspinatus, subscapularis and teres
minor. The RC functions to position and move the head of the humerus
about the glenoid fossa. In particular, the RC plays a role in lifting and
moving the arm to an overhead position and may display structural
changes in older individuals, though this could be considered a normal
part of ageing and unrelated to symptoms [50]. Despite this, RCD is
considered to be commonly associated with shoulder pain [51].
Pathology: In this disorder, one or more portions of the RC are
involved. The pathology can be due to trauma, which is most common in
the younger population, or atraumatic. Those RC injuries that occur
from trauma are most commonly following a FOOSH. In patients aged
40–75 years old, there is an estimated annual incidence of acute full-
thickness RC tears of 2.5 per 10,000 people [52].
It is a long-held theory that impingement within the subacromial
space may be the cause of RC degeneration and eventual pain and
function loss. MeSH defines “Shoulder Impingement Syndrome” as
compression of the RC tendons and subacromial bursa between the
humeral head and the acromion of the scapula [53]. This condition is
associated with subacromial bursitis, as well as RC (mainly
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International Journal of Osteopathic Medicine 42 (2021) 11–19
supraspinatus) and bicipital tendon inflammation.
It was proposed by Neer [54] that 95% of RC pathology occurs due to
the under surface of the anterior aspect of the acromion irritating the
subacromial bursa and RC tendons. Though health professions working
with shoulder pain adopted this theory, the concept appears to be
flawed. Payne et al. [55] identified that the vast majority of RC tears
occurred on the articular (inferior) aspect of the tendon, with only 9%
occurring superiorly. Several studies since have supported that the
majority of RC injuries occur either on the inferior aspect or
mid-substance [56,57]. These findings suggest that RC degeneration or
tears do not occur due to “impingement” or a physical “scraping” on the
tendon.
Diagnosis: A clinical history, physical examination and imaging
findings are all required to make an accurate diagnosis of RCD. A
retrospective chart review study investigating patients diagnosed with
RCD via arthrography identified three history and physical examination
findings that best predicted a lesion. These factors were: patients being
over the age of 65, the presence of night pain, and weakness on external
rotation [58].
A Cochrane review compared the diagnostic accuracy of magnetic
resonance imaging (MRI), magnetic resonance arthrography (MRA) and
ultrasound (US) for detecting any form of RC tear [50]. The authors
concluded that all three investigations have good diagnostic accuracy
for identifying full-thickness tears in shoulder pain patients. MRI and US
also appeared to have similar accuracy in detecting any form of RC tears.
However, both MRI and US seem to have poor sensitivity for the
detection of partial-thickness tears, and US may have a lower sensitivity
than MRI in general [50].
A literature review published in 2015 specifically investigated the
accuracy of musculoskeletal diagnostic ultrasound (MSK-DUSI) to
identify various soft tissue pathologies of the extremities [59]. The au­
thors identified 72 diagnostic studies and five systematic reviews
assessing the accuracy of MSK-DUSI for shoulder pathology. The review
highlighted the strength of US to both confirm and rule out the presence
of a full-thickness RC tear. Furthermore, it confirmed that US has a
higher specificity (0.75–0.98) than sensitivity (0.46–0.84) for those
patients with partial thickness tears.
Radiographs may also identify calcific tendinitis, subacromial spurs,
superior migration of the humeral head and cysts within the humeral
head. But these findings are now often considered to be normal findings
that are present also in the asymptomatics [60].
Prevalence: A 2014 systematic review pooled participant data from
thirty studies investigating the prevalence of rotator cuff abnormalities
according to age [61]. The results suggest that the prevalence increases
with age (almost two thirds of those over 80 years), and is almost as high
amongst asymptomatic people [61]. This further supports the theory
rotator cuff abnormalities are normal findings in an aging shoulder.
Subacromial/deltoid bursitis. Definition: Inflammation of the bursa that
lies deep to the deltoid, the anterior acromion and the coracohumeral
ligament and superficial to the RC and may be associated with RCD [62].
Pathology: Bursae are capable of producing pain via myelinated A-
delta and nonmyelinated C-fibres, which could be triggered by inflam­
matory products [63]. One study proposed that both the mechanore­
ceptors and nociceptors in the bursa could alert the body to pain and
play a role in limiting pressure between the coracoid/acromion and the
RC [64].
Subacromial pain syndrome (SAPS). Definition: This contemporary term
includes a range of non-traumatic shoulder problems causing unilateral
pain localised to the acromion area and are aggravated or occur after
lifting the arm [65]. SAPS includes a variety of clinical and radiological
names: bursitis, supraspinatus tendinopathy, partial tear of the RC, bi­
ceps tendinitis, and tendon cuff degeneration. The potential for tendons
to be a source of pain remains controversial but expression of
C. Hodgetts and B. Walker International Journal of Osteopathic Medicine 42 (2021) 11–19

nociceptive substances and innervation could explain this tendon based Table 1
pain [66]. Orthopaedic Tests for the shoulder region.
Diagnosis: Diagnostic tests aimed at identifying SAPS currently rate Orthopaedic Associated Sensitivity Specificity LR+ LR-
poorly on inter-rater reliability and have insufficient diagnostic accu­ tests Condition (%) (%)
racy. However, a cluster of tests including a positive Hawkins-Kennedy, Hawkins- Impingement/ 74 57 1.7 0.46
a painful arc on shoulder elevation, and resisted external rotation have Kennedy rotator cuff
been recommended in guidelines as a means of determining the presence [74] disorder
of SAPS [65]. Drop-arm [74] Large rotator 21 92 2.62 0.86
cuff tear
Prevalence: In a 12-month prospective cohort study in a hospital- Empty-can test Supraspinatus 69 52 1.81 0.50
outpatient setting, SAPS was found to be the most common shoulder [74] involvement
diagnosis (36%) [67]. The authors also found that SAPS increases with Lift-off test Subscapularis 42 97 16.47 0.59
age. [74] involvement
Resisted Infraspinatus 51 84 3.2 0.58
Prognosis: Evidence suggests an association between chronic shoul­
external involvement
der pain present for greater than three months and a poorer outcome rotation [75]
[65,68]. People between 45 and 54-years tend to have a worse result. A Horizontal AC joint sprain 77 79 3.50 0.29
prospective cohort study suggested that psychosocial factors also appear abduction or OA
to have a greater association with the course and prognosis of chronic vs [76]
Active Chronic AC 41 95 8.2 0.62
short-term pain [65]. Compression joint lesion
Test [76]
Other shoulder conditions. Other shoulder conditions include sprains to Apprehension Glenohumeral 72 96 20.22 0.29
those ligaments and joints surrounding the shoulder complex or bony test [77] instability
Relocation test Glenohumeral 81 92 10.35 0.2
fractures. Acromioclavicular (AC) joint sprain, sternoclavicular sprain, [77] instability
or clavicle fractures are injuries that occur amongst athletes partici­
pating in contact sports. The mechanism most commonly responsible is LR+ = positive likelihood ratio; LR- = negative likelihood ratio; OA = osteo­
arthritis.
either direct contact of the point of the shoulder with the ground or
Adapted and reprinted from American Academy of Family Physicians (AAFP),
another object/person while in an adducted position or it can occur
77/4, Kelton M Burbank, J Herbert Stevenson, Gregory R Czarnecki, Justin
indirectly as a result of a FOOSH injury [69].
Dorfman, Chronic Shoulder Pain: Part I. Evaluation and Diagnosis, Page 453,
Diagnosis: Diagnosis for these conditions is based on a combination Copyright (2008), with permission from AAFP.
of clinical findings (i.e. history of trauma), the recreation of pain on
localised palpation, and radiographic results [70]. AC joint sprains can
Interventions
be classified based on the number of ligaments involved and the superior
migration of the clavicle in relation to the acromion [71]. Sternocla­
Surgery
vicular sprains can be similarly classified. Clavicle fractures are classi­
Systematic reviews have failed to show a difference between surgical
fied based on the degree of displacement and number of fragments
procedures (open and arthroscopic) and conservative care (including
involved [72].
exercise therapy, education or passive modalities) for shoulder
impingement between and six months and eight years follow-up [79],
Assessment
and RC tears after one year [80]. Furthermore, a Cochrane review
published in 2019 identified eight RCTs investigating subacromial
This review has already explored the potential for particular aspects
decompression surgery for shoulder impingement and concluded that
of clinical history, physical examination or imaging to contribute to the
decompression surgery does not provide clinically important benefits
specific diagnoses of a complaint of shoulder pain. However, other
over placebo in the domains of pain, function and health-related quality
physical assessment procedures are worthy of investigation and are
of life after one year [81].
summarized below.
These results are especially pertinent in light of the risks and costs of
Physical examination tests seek to recreate the patient’s pain by
surgery when compared to conservative care. Patients who undergo
provocation. Unfortunately, there are more than 180 different ortho­
physiotherapy management tend to have lower overall health care
paedic test procedures for the shoulder, many of which have little data to
expenditure [15]. In addition, recent literature suggests surgeons may
support their use [45]. As has been identified with diagnoses, there is
not be adhering to the evidence, e.g. there has been a substantial in­
often confusion around tests due to overlap in both procedure and label.
crease in arthroscopic surgery rates for RCD and associated costs in
In 2008, Burbank et al. provided a summary of aspects of physical
Western Australia between the years of 2001 and 2013 [82].
examination that are associated with shoulder conditions [73]. In
addition to this, Table 1 provides values for common orthopaedic tests
Conservative treatments
for shoulder conditions; Hawkins-Kennedy, drop-arm, empty-can and
lift-off tests as pooled results from a systematic review [74]. The diag­
Exercise. A 2015 systematic review found five RCTs investigating the
nostic value of these tests depends on the study population, whether
efficacy of exercise strategies for the management of shoulder soft tissue
they were performed in the primary sector or secondary sector, in a
injuries [83]. The authors concluded that “supervised progressive
surgeon or physiotherapy clinic. Critical analysis investigating the in­
shoulder exercises alone or combined with home-based shoulder exer­
dividual studies is beyond the scope of this review, but these studies
cises (strengthening ± stretching) are effective over the short-term for
would need to be replicated to build confidence in the reported results.
the management of SA impingement of variable duration”. Perhaps
The recent literature investigating the accuracy of diagnostic tests
more importantly, two randomised controlled trials (RCTs) concluded
has focused on the contemporary diagnostic label of SAPS, e.g. Michener
that supervised or home-based progressive strengthening exercise had
et al. [78] found that 3+/5 positive tests from a cluster of
similar long-term outcomes to acromioplasty [84,85].
Hawkins-Kennedy, Neer, painful arc, empty-can, and external rotation
resistance tests had 75% sensitivity and 74% specificity for SAPS in an
individual with shoulder pain present for at least 1 one week. Acupuncture. Acupuncture is now a common intervention incorporated
in the management of adhesive capsulitis, RCD and osteoarthritis. It is
contended that needling has an analgesic effect. A Cochrane review

15

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C. Hodgetts and B. Walker
identified nine studies that included more than 500 people with shoul­
der pain [86]. The studies varied in quality, but ultimately the review
concluded that there is currently not enough evidence to suggest
acupuncture is an effective modality for shoulder pain [86].
Corticosteroid injection. Subacromial injection of corticosteroid is
commonly used for subacromial conditions, but there is conflicting ev­
idence on its effectiveness. Several systematic reviews [87–89] found
that there was generally poor quality research on the efficacy of this
intervention, with a further two reviews finding that the injections had a
positive impact on shoulder abduction range of motion [90,91]. The
most recent systematic review included a further two articles in the
meta-analysis as the data was relevant to assessing the effectiveness and
allowed the number needed to treat (3.3) to be calculated [92]. Ac­
cording to the authors, corticosteroid injections are more effective than
non-steroidal anti-inflammatories and could provide benefits for any­
where from 3 to 38 weeks post-intervention, with higher doses being
more effective than lower doses [92].
Manual therapy. Mobilisation and manipulation of the glenohumeral
joint, scapulothoracic joint, thoracic spine and cervical spine are
frequently part of the management of RCD [93]. This manual therapy is
often delivered in conjunction with exercise therapy and other physio­
therapy modalities. Literature from RCTs suggest manual therapy
applied as a package (including soft tissue massage, GH joint mobi­
lisation, thoracic spine mobilisation, cervical spine mobilization, scap­
ular retraining, postural taping, and at-home RC strengthening
exercises) or in isolation does not provide clinically significant im­
provements in pain, function and quality of life when compared to
placebos [94–97].
Mobilisation with movement (MWM), such as the Mulligan tech­
nique of applying anterior to poster glide on the humeral head while the
patient moves the arm in and out of shoulder elevation, has immediate
statistically and clinically significant changes in active range of motion,
as compared to a sham intervention, although the duration of this effect
is unknown [96].
Taping. A recent systematic review investigating the effects of taping on
patients with subacromial pain concluded that there were moderate
levels of evidence that kinesiotaping had no additional benefits to pla­
cebo taping in regards to pain, function or range of motion [98]. There
was limited data to suggest that kinesiotaping may assist more with
night pain compared to manual therapy, when combined with exercise
and cold packs [99]. There was no evidence to suggest that prophylactic
taping reduces the incidence of a shoulder injury in either athletes or
those in the general population.
Low-level laser therapy. Laser therapy is a common intervention in the
management of musculoskeletal pain and is proposed to trigger
biochemical changes to the peripheral nerve endings of nociceptors,
inhibiting action potentials and therefore reducing pain [100]. Haik
et al. [98] concluded in their systematic review that there was moderate
evidence suggesting laser therapy is not effective in improving pain,
function and range of motion when compared to a placebo or exercise
combined with laser therapy. The authors acknowledged that doses
were not consistent across the trials included and that those with higher
reported doses appeared to be more effective in reducing pain.
Therapeutic ultrasound. The application of therapeutic ultrasound aims
to increase target tissue temperature and increase cell permeability and
growth. Theoretically this aids in promoting soft tissue healing [101].
Littlewood et al. identified five systematic reviews of variable quality
investigating the effectiveness of ultrasound for RC tendinopathy. The
reviews consistently concluded that evidence does not support ultra­
sound as an effective modality in RC tendinopathy patients [102].
16
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personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2024. Elsevier Inc. Todos los derechos reservados.
International Journal of Osteopathic Medicine 42 (2021) 11–19
Prognosis
Shoulder pain has been considered to be self-limiting, but research
does not support this long-held belief. Several studies have revealed that
only 50% of all new incidents of shoulder pain completely recovery after
six months, and this only increases to 60% after 12 months [103–105].
The trajectory of pain has previously been investigated for neck and
lower back pain [106–110]. This is a gap in the current literature, which
requires further study.
Prognostic factors
Duration
Although the trajectories of shoulder pain are unknown, a prospec­
tive cohort study of GP patients with shoulder conditions found that
those presenting with acute pain fared better than sub-acute and chronic
pain at the 6-month follow up regarding both pain and function, but
there were minimal differences in quality of life [68]. Another pro­
spective study reported that the most influential single predictor for
persistent pain was long-lasting pain of greater than three months [111].
Pain intensity and disability
Several high-quality studies linked higher shoulder pain intensity at
the first consultation with a poorer outcome [103,112–114]. However,
one cohort study did report that higher levels of pain and lower levels of
disability at baseline were predictive of a better outcome at the 6-month
follow-up for acute presentations [68]. This may seem counterintuitive,
but logically higher pain levels provide a larger scope for improvement
regarding pain scores. Lower pain scores will have lower percentage
changes, even if recovery is occurring.
However, in secondary care populations such as outpatient de­
partments, there was substantial evidence suggesting an association
between high levels of disability (Shoulder Pain And Disability Index)
and poorer outcomes [115,116].
Concomitant symptoms
A prospective study found that participants with shoulder pain and
more than four concurrent symptoms and clinical findings were >3
times likely to utilise health care resources as compared to those with no
concurrent symptoms or signs [111]. Concurrent symptoms or clinical
outcomes reported at baseline included: ongoing pain, long-lasting pain
of more than seven consecutive days, decreased range of motion in the
neck or shoulder region, radiating pain, trauma, previously sought care
and concomitant low back pain. In other research, concurrent neck pain,
has been identified as having a strong association with a poorer outcome
for patients with shoulder pain [103,112,114]. Musculoskeletal pain
that originates in the neck can refer to the shoulder region, so it is
possible that the poorer outcome is associated with pathology or lesion
in the neck, rather than the shoulder directly.
Range of motion
A cross-sectional study concluded that there was a relationship be­
tween restricted shoulder movements and self-reported shoulder pain
[117]. A prospective cohort study also reported that patients with
limited shoulder movements had a 40% increased risk that their pain
would become persistent [113]. But, it is important to note that the
frequency of restricted shoulder movements was also reasonably high in
the pain-free participants. Shoulder pain patients with decreased range
of motion in both the neck and shoulder region had a 27% increased risk
for persistent pain [111].
Psychosocial factors
Psychosocial factors appear to influence the prognosis of shoulder
pain patients. Chronic shoulder presentations with higher scores on pain
catastrophising scales are more likely to have smaller reductions in pain
at the 6-month follow-up [68] and those patients presenting with
C. Hodgetts and B. Walker
chronic pain have higher levels of catastrophising at baseline when
compared to acute pain, which may suggest that it is a consequence of
having chronic pain, rather than the reason for it [68].
Other psychosocial factors that have previously been proposed to
predict poor outcomes for musculoskeletal pain include somatisation
and fear avoidance beliefs, but this has not been established with
shoulder pain [68,118–120].
Conclusion
In summary, the presence of shoulder pain has a wide range of
prevalence estimates. The most common diagnoses are adhesive cap­
sulitis, osteoarthritis, long head of biceps pathology, labral lesions, and
subacromial diagnoses such as rotator cuff disease and bursitis. How­
ever, it is important to note that diagnostic labels change and are
adapted as new research comes to hand, but many of old labels remain.
This may cause confusion amongst clinicians and patients.
Surgery is still a common treatment for shoulder impingement and
rotator cuff tears although the evidence does not support decompression
surgery or tendon repair. Contrary to previous beliefs, shoulder pain
does not appear to be self-limiting and several factors appear linked with
a worse prognosis including: increased duration and intensity of pain,
higher levels of disability, catastrophizing, presence of concomitant
symptoms and range of motion loss.
There is no published data available about the trajectories of
shoulder pain in the general population. Understanding what happens to
shoulder pain over time is important for both clinicians and researchers
because it could underpin clinical decisions needed for intervention
decision making.
Ethical approval
Not applicable
Competing interests
There are no financial interests or other competing interests for the
principal investigators for the overall trial. Members of the research
team are members of the academic staff at Murdoch University.
Funding
No funds were received in support of this work.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://doi.
org/10.1016/j.ijosm.2021.10.006.
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