The study by Crawshaw and colleagues aims to investigate if the use of exercise therapy in the "window" of opportunity after a corticosteroid injection results in better outcomes for patients with subacromial impingement syndrome compared with exercise therapy alone. Shoulder pain is common, particularly in individuals who are >40 years of age, and is often persistent, with half of those presenting in primary care still having symptoms 18 months later. Shoulder pain is not a diagnosis, and many previous studies have failed to discriminate between tendinopathy (impingement syndrome) and capsulitis or arthritis. This study includes clinical examination by experienced physiotherapists to pragmatically screen patients and thereby investigates a substantially more homogeneous population than those of other studies. The finding that steroids produced significant short-term benefit in terms of pain and restoration of function is consistent with other studies. Whether or not steroid injection plus exercise therapy was any more or less effective than steroid injection alone was not addressed in this study. Nor was there a comparison with no treatment or observation. Similar to other injection studies, no short-term harmful effects or complications were reported (e.g., tendon rupture). However, we cannot determine any long-term deleterious effects of steroids with a study end point of only 12 weeks. One-third of patients treated with exercise alone subsequently opted for steroid injection. More importantly, 14% to 19% of patients in both groups were no better or worse and an additional 72% were improved but still having problems at 24 weeks. No imaging of the rotator cuff was undertaken, and we do not know if the presence of a rotator cuff tear influences outcome. In conclusion, surgeons should continue to use steroid injections for patients in whom a short-term improvement is desired. However, this study highlights the need for a better understanding of the disease mechanisms underlying rotator cuff tendinopathy and the discovery of more effective treatment strategies. Crawshaw DP, Helliwell PS, Hensor EM, Hay EM, Aldous SJ, Conaghan PG. Exercise Therapy After Corticosteroid Injection for Moderate to Severe Shoulder Pain: Large Pragmatic Randomised Trial. BMJ. 2010 Jun 28;340:c3037. [Abstract/ Free Full Text]
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Combined Treatment with Corticosteroid Injection Plus Exercise and Manual Therapy Was Similar to Exercise and Manual Therapy Alone for Shoulder Pain at 12 Weeks
Carr, Andrew
Follow Journal of Bone and Joint Surgery
, Volume 93 (10): 971
JB&JS – May 18, 2011
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