Shoulder Pain: Why More Treatment Is Not Always Better

What the GRASP trial found

The GRASP trial, published in The Lancet in 2021, included more than 700 adults with a new episode of rotator cuff related shoulder pain. One group received a progressive exercise program delivered across up to six physiotherapy sessions, while another received a single best-practice physiotherapy session with advice and a home exercise program. Over 12 months, the more intensive supervised program was not clearly superior to the best-practice advice approach for pain and disability. That is a useful finding for patients because it changes the emphasis from "How many treatments do I need?" to "Have we identified the right problem, given the right exercise and created a sensible plan for progression?"

Assessment still matters

Shoulder pain is an umbrella term rather than a diagnosis. Rotator cuff related pain, frozen shoulder, instability, arthritis, traumatic tendon injury and pain referred from the neck can look similar at first. Physiotherapy assessment considers the history, mechanism of injury, range of movement, strength, painful movements, neck and neurological findings and the demands the shoulder must eventually tolerate. For many rotator cuff presentations, the plan centres on education and progressive loading of the shoulder and upper limb. The starting point may be very simple, but later exercises should increasingly resemble the work, gym, swimming, throwing or racquet demands the patient wants to return to.

The right amount of follow-up

The GRASP findings do not mean that everyone needs only one visit. They suggest that routine high-frequency treatment is not automatically better. Follow-up is most valuable when it changes a decision: progressing resistance, checking strength, modifying technique, dealing with a flare, confirming that motion is returning, or reconsidering the diagnosis when progress stalls. Hand-held dynamometry, range of measurements and functional tests can make these decisions more objective. A patient who is steadily improving and independently progressing may need relatively little supervision. Someone with major weakness after trauma, marked stiffness, recurrent instability or an unexpected course may need closer review or further imaging and medical input. Good physiotherapy is therefore not measured by the number of visits. It is measured by whether each visit adds value to recovery.

Selected research

1. Hopewell S, Keene DJ, Heine P, et al. Progressive exercise compared with best practice advice, with or without corticosteroid injection, for rotator cuff disorders (GRASP). The Lancet.2021;398(10298):416-428.doi:10.1016/S0140-6736(21)00846-1.

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