Table 1 Recommendations from selected high quality clinical practice guidelines on the management of shoulder disorders used to assess appropriateness of care offered by physiotherapists and family physicians
Shoulder disorders | Initial management | Medical treatment | Rehabilitation treatment |
|---|---|---|---|
Rotator cuff tendinopahy | X-rays are the first line examination for shoulder pain [6]/X-rays are not initially indicated in the initial management of RC tendinopathy [13, 17] (Conflicting recommendationsa) US or MRI are not recommended in the initial management of RC tendinopathy [17] A referral to a medical specialist is not recommended in the initial management of RC tendinopathy [17] | Acetaminophen is recommended for pain relief [17]. Oral NSAIDs may be useful for short term pain relief [17]. Corticosteroids injections are not recommended as first line treatment to reduce pain and improve function, but may be useful to reduce pain and improve short term function [17]. Opioids are not recommended as first line pharmalogical treatment to reduce pain in disability. Opioids may be useful to reduce short term pain in adults that present severe pain and disability refractory to other analgesic modalities [17]. | An active and functional rehabilitation program is recommended as an initial modality to reduce pain and improve function (Mobility, motor control, strengthening, endurance, education). It is recommended to prioritize active mobilization to passive modalities to reduce pain and improve function [17]. Manual therapy can be useful provided alone or with other modalities such as exercises to reduce pain and improve function [17]. Ultrasound, laser and extracorporeal shockwave treatment are not recommended to reduce pain and improve function [17]. Insufficient evidence to formulate recommendations for taping, TENS, iontophoresis, pulsed electromagnetic field, interferential current [17]. |
Acute full-thickness rotator cuff tear | X-ray, US or MRI are recommended in the presence of a suspected FT RC tear. US should be prioritized, when possible, because of lower costs and diagnostic properties similar to MRI [17]. A referral to a medical specialist is recommended in the suspicion of FT RC tear confirmed by an imaging test in the presence of important pain and/or muscular weakness and/or a significant activity limitation [17, 18]. | Acetaminophen may be useful for short term pain relief [17]. Oral NSAIDs may be useful for short term pain relief [17]. Corticosteroids injections are not recommended as first line treatment to reduce pain and improve function, but may be useful to reduce pain and improve short term function [17]. Opioids are not recommended as first line pharmacological treatment to reduce pain in disability. May be useful to reduce short term pain in adults that present severe pain and disability refractory to other analgesic modalities [17]. | An active rehabilitation program is recommended as an initial modality. Active modalities such as exercises should be included as early as possible [17]. Insufficient evidence to formulate recommendations for iontophoresis, pulsed electromagnetic field, interferential current [17]. |
Adhesive capsulitis | X-rays are not initially indicated [13]. Referral to a medical specialist for a surgical opinion: No recommendation regarding adding manipulation under anesthesia [14]. | No recommendation from CPGs on use of acetaminophen NSAIDs is recommended in combination with outpatient physiotherapy (with passive mobilizations) [14]. An intra-articular steroid injection is recommended, preferably in combination with outpatient physiotherapy (with passive mobilizations) [14]. No recommendation from CPGs on opioids use | Outpatient physiotherapy (with passive mobilizations) with home exercises is recommended [14]. For stiffness-predominant frozen shoulder, probably use high grade mobilizations in preference to low grade mobilizations [14]. Thermotherapy is not recommended [14]. |
Traumatic anterior glenohumeral instability | Advanced diagnostic imaging (MRI, MRA) is recommended [6, 13]. Referral to a medical specialist for a surgical opinion: Arthroscopic or open surgery is recommended for acute first anterior shoulder dislocation, particularly in patient under age 27 [16]. | Acetaminophen is recommended [16]. Oral NSAIDs are recommended [16]. No recommendation from CPGs on corticosteroid infiltration Judicious short-term use of opioids is recommended for pain management for select patients with acute moderate to severe pain associated with shoulder dislocation. Opioids are not recommended for subacute or chronic pain [16]. | Exercises are recommended [16]. Thermotherapy is recommended [16]. No recommendation for manual therapy, therapeutic ultrasound, TENS, iontophoresis, laser [16]. Taping, pulsed electromagnetic field and interferential current are not recommended [16]. |