Time to change how we assess and manage shoulder pain

Over the past 12 months, key papers have emerged that change the way we manage shoulder pain. Two landmark randomised controlled trials in the United Kingdom and Finland have found no difference in outcome of subacromial decompression shoulder surgery for rotator cuff problems when compared to placebo surgery or no treatment. Although shoulder surgery is commonly recommended, current evidence suggests similar outcomes with a conservative management approach for some procedures.

Traditionally, management of shoulder pain has followed a structural model where assessment, diagnosis and treatment has been based on the search for patho-anatomical changes on imaging.   Incidental age-related changes are commonly observed on imaging in people without shoulder pain, particularly in older age and in those without a history of shoulder injury. A focus on structure is not helpful with contemporary healthcare pathways supporting a biopsychosocial approach for understanding and managing musculoskeletal pain. This approach has been widely endorsed for conditions such as low back pain, hip and knee osteoarthritis, but not yet consistently translated into clinical practice for shoulder pain.

Key findings from our recent research support the move towards a biopsychosocial approach for shoulder pain. Our study identified that a group of people with worse psychological function showed higher levels of pain and disability before and after shoulder surgery than a group with better psychological function. Although both groups showed improvements in pain and disability after surgery, the group with worse psychological function continued to experience greater pain and disability after one year.  Early screening and identification of poor psychological function may identify people who could benefit from behavioural or psychological interventions before consideration of surgery, however this is an area that requires further research.

For management of shoulder pain, consumers need to seek out health professionals who deliver high value care and engage people as active participants in their own healthcare decision-making and recovery. First line care for shoulder pain should provide realistic expectations for recovery and may provide self-management advice including activity modification, adequate rest and recovery, maintenance of physical activity, cessation of smoking, dietary advice and may include simple analgesia. Behavioural interventions may be indicated for people with evidence of low moods and emotions or negative beliefs. Failure to respond after an initial minimum three month period of first line care may indicate the need for alternative pathways to target barriers to recovery. Second line care may encompass a multidisciplinary approach and may include surgeon, pain specialist, specialist physiotherapist or clinical psychologist opinion. Further research is needed to inform if consistent, evidence informed messages can be delivered to improve management outcomes for shoulder pain.


Alison Thorpe is a lecturer at the School of Physiotherapy and Exercise Science at Curtin University, Perth and a Specialist Sports Physiotherapist (as awarded by the Australian College of Physiotherapists 2009) consulting in clinical practice at Perth Shoulder Rehabilitation. Alison completed her PhD investigating shoulder surgery trends, surgical criteria and factors associated with outcome after shoulder surgery in 2018.

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