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Shoulder Pain - Physiotherapy or Shoulder Injection?

Abstract: In the first-ever study comparing physiotherapy to corticosteroid injections for shoulder impingement syndrome, the outcomes for pain and disability were the same. Physiotherapy patients proved 38% less likely to seek non-study attention for their shoulders. Physiotherapy may do more to address the underlying pathology while also giving patients greater ability and confidence in future self-management.

May 2016 Latest Research on Shoulder Pain

Dr. Daniel Rhon and colleagues recently published what they report to be the first direct comparison of cortisone injections versus physiotherapy in the treatment of shoulder impingement syndrome.1 They use shoulder impingement syndrome as a generic term to encompass rotator cuff syndrome, tendinosis of the rotator cuff muscles, and shoulder bursitis. Among 104 randomised patients, both groups showed clinically significant improvement as measured by the Shoulder Pain and Disability Index (SPADI). Both treatments created a roughly 50% improvement in the SPADI score in one month and maintained that improvement at three, six, and twelve month follow-up. With the exception of healthcare utilization, there was no clinically significant difference or statistically significant difference in any of the outcome measures in the study at any time point.

The main difference between the groups is that patients receiving physiotherapy proved far less likely to seek additional treatment. Compared to patients receiving injections, physiotherapy patients were 38% less likely to have shoulder-related doctor visits that were not part of the study treatments, additional shots, additional physiotherapy, or other healthcare services related to the shoulder impingement syndrome. This difference stands out since both groups apparently achieved the same success in pain and disability improvement in one month and both maintained that success. The authors theorise that largely passive treatments may encourage dependence on professional intervention while physiotherapy may teach and empower patients to self-manage more effectively and more confidently.

Differences may also manifest in that physiotherapy programs can be designed to directly address the underlying pathology, and thereby do more to thwart the progression of shoulder impingement syndrome. On the other hand, it is theorised that corticosteroid injections would have less to offer in terms of addressing the underlying pathology of rotator cuff syndrome or tendinosis. For example, when corticosteroids alone are used to treat shoulder impingement syndrome, Ramirez and col-leagues found that 17% later experience a full-thickness tear, even though patients reported a decrease in pain.2

Physiotherapy promises equally effective improvements in pain and disability plus an intention to empower patients in self-management while decreasing the progression of the disease. Rhon’s work adds to the work of Kukkonen and colleagues who found that physiotherapy as a first line treatment for non-traumatic rotator cuff tears achieves outcomes comparable to arthroscopic surgery.3


Rhon D, Boyles R, Cleland J. One-year outcome of subacromial corticosteroid injection com-pared with manual physical therapy for the management of the unilateral shoulder impinge-ment syndrome: a pragmatic randomized trial. Annals of Internal Medicine. 2014 Aug 5;161(3):161-9.

2. Ramirez J, Pomes I, Cabrera S, et al. Incidence of full-thickness rotator cuff tear after sub-acromial corticosteroid injection: a 12-week prospective study. Mod Rheumatol. 2014; 24 (4): 667-70.

3. Kukkonen J, Joukainen A, Lehtinen J, et al. Treatment of non-traumatic rotator cuff tears: a randomised controlled trial with one-year clinical results. Bone Joint J. 2014; 96-B: 75-81

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