Physical therapy and corticosteroid injections offer equal relief from shoulder pain and disability

Both physical therapy and subacromial corticosteroid injections provide significant improvement in pain and function for patients with unilateral shoulder impingement syndrome, according to a study in the Aug. 5 Annals of Internal Medicine.

Researchers randomly assigned 104 patients between the ages of 18 and 65 in a U.S. military hospital-based outpatient clinic to receive either as many as 3 total injections of subacromial injections of triamcinolone acetonide, 40 mg, at least 1 month apart during the 1-year period or 6 sessions of physical therapy over a 3-week period. Patients were treated for shoulder conditions such as rotator cuff tendinosis and shoulder bursitis. Physical therapy was matched to individual impairments and included a combination of joint and soft-tissue mobilizations; manual stretches; contract-relax techniques; and reinforcing exercises directed to the shoulder girdle or thoracic or cervical spine. Home exercises were prescribed to reinforce clinical interventions.

In the study, both groups experienced about a 50% improvement in Shoulder Pain and Disability Index scores maintained through 1 year, and the mean difference between groups was not significant (1.5%; 95% CI, −6.3% to 9.4%). Both groups showed improvements in Global Rating of Change scale and pain rating scores, and between-group differences were not significant for the Global Rating of Change scale (0; 95% CI, −2 to 1) and pain rating (0.4; 95% CI, −0.5 to 1.2).

During 1-year follow-up, patients receiving injections visited their primary care clinician more often (60% vs. 37%; risk ratio [RR], 0.64; 95% CI, 0.43 to 0.95), required additional steroid injections (38% vs. 20%; RR, 0.77; 95% CI, 0.59 to 0.99), and needed more physical therapy (19% vs. 9%). The authors concluded that patients in both groups experienced significant improvement in pain and function, but the physical therapy patients used less shoulder-related health care resources than the injections group.

An editorial noted, “Results of this trial and others suggest no long-term differences in clinical outcomes for patients with shoulder pain regardless of clinical intervention, setting, or diagnosis. In choosing a management plan, clinicians should consider patient preference, availability of practitioners, and other health care use. If a patient prefers a more active or self-management approach, manual physical therapy, exercise, and referral to a physiotherapist should be discussed. If the patient prefers a corticosteroid injection, its effectiveness, safety profile, and potential for additional health care should be discussed.”