Addressing Rotator Cuff-Related Shoulder Pain: Findings from a Greek Regional Observational Study Utilizing a Clinical Case Scenario
Abstract
:1. Introduction
2. Materials and Methods
2.1. Study Design
2.2. Survey Questionnaire
2.3. Assessment of Optimal Treatment Approaches
2.4. Statistical Analysis
3. Results
3.1. Care Recommendations for the Clinical Vignette
3.2. Physiotherapy Management
3.3. Provision of Instructions Regarding Exercise
3.4. Open-Ended Questions Analysis
4. Discussion
4.1. Referral for Imaging, Injection, and Surgery
4.2. Patient Education
4.3. Exercise Recommendations
4.4. Adjunctive Treatment Modalities
4.5. Limitations
5. Conclusions
Supplementary Materials
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
- Paraskevopoulos, E.; Plakoutsis, G.; Chronopoulos, E.; Maria, P. Effectiveness of combined program of manual therapy and exercise vs exercise only in patients with rotator cuff-related shoulder pain: A systematic review and meta-analysis. Sports Health A Multidiscip. Approach 2023, 15, 727–735. [Google Scholar] [CrossRef] [PubMed]
- Smythe, A.; Rathi, S.; Pavlova, N.; Littlewood, C.; Connell, D.; Haines, T.; Malliaras, P. Self-reported management among people with rotator cuff related shoulder pain: An observational study. Musculoskelet. Sci. Pract. 2021, 51, 102305. [Google Scholar] [CrossRef] [PubMed]
- Lewis, J. Rotator cuff related shoulder pain: Assessment, management and uncertainties. Man. Ther. 2016, 23, 57–68. [Google Scholar] [CrossRef] [PubMed]
- Lewis, J. Should we provide a clinical diagnosis for people with shoulder pain? Absolutely, maybe, never! The ongoing clinical debate between leavers and retainers. N. Z. J. Physiother. 2023, 50, 4–5. [Google Scholar] [CrossRef]
- Powell, J.K.; Schram, B.; Lewis, J.; Hing, W. “You have (rotator cuff related) shoulder pain, and to treat it, I recommend exercise.” A scoping review of the possible mechanisms underpinning exercise therapy. Musculoskelet. Sci. Pract. 2022, 62, 102646. [Google Scholar] [CrossRef]
- Powell, J.K.; Lewis, J.; Schram, B.; Hing, W. Is exercise therapy the right treatment for rotator cuff-related shoulder pain? Uncertainties, theory, and practice. Musculoskelet. Care 2024, 22, e1879. [Google Scholar] [CrossRef]
- Yiasemides, R.; Halaki, M.; Cathers, I.; Ginn, K.A. Does passive mobilization of shoulder region joints provide additional benefit over advice and exercise alone for people who have shoulder pain and minimal movement restriction? A randomized controlled trial. Phys. Ther. 2011, 91, 178–189. [Google Scholar] [CrossRef]
- Codsi, M.; Howe, C.R. Shoulder conditions: Diagnosis and treatment guideline. Phys. Med. Rehabil. Clin. N. Am. 2015, 26, 467–489. [Google Scholar] [CrossRef]
- Diercks, R.; Bron, C.; Dorrestijn, O.; Meskers, C.; Naber, R.; De Ruiter, T.; Willems, J.; Winters, J.; Van Der Woude, H.J. Guideline for di-agnosis and treatment of subacromial pain syndrome: A multidisciplinary review by the Dutch Orthopaedic Association. Acta Orthop. 2014, 85, 314–322. [Google Scholar] [CrossRef]
- Hopman, K.; Krahe, L.; Lukersmith, S.; McColl, A. Clinical Practice Guidelines for the Management of Rotator Cuff Syndrome in the Workplace; University of New South Wales: Sydney, Australia, 2013. [Google Scholar]
- Riera, J.; Smythe, A.; Malliaras, P. French physiotherapy management of rotator cuff related shoulder pain: An observational study. Musculoskelet. Care 2021, 19, 484–494. [Google Scholar] [CrossRef]
- Baumgarten, K.M.; Chang, P.S.; Dannenbring, T.M.; Foley, E.K. Does arthroscopic rotator cuff repair improve patients’ activity levels? J. Shoulder Elb. Surg. 2018, 27, 2167–2174. [Google Scholar] [CrossRef] [PubMed]
- Ketola, S.; Lehtinen, J.; Arnala, I.; Nissinen, M.; Westenius, H.; Sintonen, H.; Aronen, P.; Konttinen, Y.T.; Malmivaara, A.; Rousi, T. Does arthroscopic acromioplasty provide any addi-tional value in the treatment of shoulder impingement syndrome?: A two-year randomised controlled trial. J. Bone Jt. Surg. Br. 2009, 91, 1326–1334. [Google Scholar] [CrossRef] [PubMed]
- Piper, C.C.; Hughes, A.J.; Ma, Y.; Wang, H.; Neviaser, A.S. Operative versus nonoperative treatment for the management of full-thickness rotator cuff tears: A systematic review and meta-analysis. J. Shoulder Elb. Surg. 2018, 27, 572–576. [Google Scholar] [CrossRef] [PubMed]
- Saltychev, M.; Äärimaa, V.; Virolainen, P.; Laimi, K. Conservative treatment or surgery for shoulder impingement: Systematic review and meta-analysis. Disabil. Rehabil. 2015, 37, 1–8. [Google Scholar] [CrossRef]
- Bury, J.; Littlewood, C. Rotator cuff disorders: A survey of current (2016) UK physiotherapy practice. Shoulder Elb. 2018, 10, 52–61. [Google Scholar] [CrossRef]
- Pieters, L.; Voogt, L.; Bury, J.; Littlewood, C.; Feijen, S.; Cavaggion, C.; Struyf, F. Rotator CUFF disorders: A survey of current physiotherapy practice in Belgium and the Netherlands. Musculoskelet. Sci. Pract. 2019, 43, 45–51. [Google Scholar] [CrossRef]
- Peabody, J.W.; Luck, J.; Glassman, P.; Dresselhaus, T.R.; Lee, M. Comparison of vignettes, standardized patients, and chart abstraction: A prospective validation study of 3 methods for measuring quality. JAMA 2000, 283, 1715–1722. [Google Scholar] [CrossRef]
- Kulkarni, R.; Gibson, J.; Brownson, P.; Thomas, M.; Rangan, A.; Carr, A.J.; Rees, J.L. Subacromial shoulder pain. Shoulder Elb. 2015, 7, 135–143. [Google Scholar] [CrossRef]
- Castleberry, A.; Nolen, A. Thematic analysis of qualitative research data: Is it as easy as it sounds? Curr. Pharm. Teach. Learn. 2018, 10, 807–815. [Google Scholar] [CrossRef]
- Paraskevopoulos, E.; Gioftsos, G.; Georgoudis, G.; Papandreou, M. Perceived barriers and facilitators of sports rehabilitation adherence in injured volleyball athletes: A qualitative study from Greece. J. Clin. Sport Psychol. 2023, 17, 86–105. [Google Scholar] [CrossRef]
- Whiteley, R.; Napier, C.; Van Dyk, N.; Barton, C.J.; Mitchell, T.; Beales, D.; Korakakis, V. Clinicians use courses and conversations to change practice, not journal articles: Is it time for journals to peer-review courses to stay relevant? Br. J. Sports Med. 2021, 55, 651–652. [Google Scholar] [CrossRef] [PubMed]
- Leahy, E.; Chipchase, L.; Calo, M.; Blackstock, F.C. Which learning activities enhance physical therapist practice? Part 2: Systematic review of qualitative studies and thematic synthesis. Phys. Ther. 2020, 100, 1484–1501. [Google Scholar] [CrossRef] [PubMed]
- Alaiti, R.K.; Caneiro, J.; Gasparin, J.T.; Chaves, T.C.; Malavolta, E.A.; Gracitelli, M.E.; Meulders, A.; da Costa, M.F. Shoulder pain across more movements is not related to more rotator cuff tendon findings in people with chronic shoulder pain diagnosed with subacromial pain syndrome. Pain Rep. 2021, 6, e980. [Google Scholar] [CrossRef] [PubMed]
- Malliaras, P.; O’keeffe, M.; Ridgway, J.; Whale, R.; Vasan, V.; L’huillier, P.; Towers, M.; Farlie, M.K. Patient experiences of rotator cuff-related shoulder pain and their views on diagnostic shoulder imaging: A qualitative study. Disabil. Rehabil. 2024, 46, 5021–5028. [Google Scholar] [CrossRef]
- Friedman, D.J.; Tulloh, L.; Khan, K.M. Peeling off musculoskeletal labels: Sticks and stones may break my bones, but diagnostic labels can hamstring me forever. Br. J. Sports Med. 2021, 55, 1184–1185. [Google Scholar] [CrossRef]
- Malliaras, P.; Rathi, S.; Burstein, F.; Watt, L.; Ridgway, J.; King, C.; Warren, N. ‘Physio’s not going to repair a torn tendon’: Patient decision-making related to surgery for rotator cuff related shoulder pain. Disabil. Rehabil. 2022, 44, 3686–3693. [Google Scholar] [CrossRef]
- Darlow, B.; Fullen, B.; Dean, S.; Hurley, D.; Baxter, G.; Dowell, A. The association between health care professional attitudes and beliefs and the attitudes and beliefs, clinical management, and outcomes of patients with low back pain: A systematic review. Eur. J. Pain 2012, 16, 3–17. [Google Scholar] [CrossRef]
- Dean, B.J.F.; Lostis, E.; Oakley, T.; Rombach, I.; Morrey, M.E.; Carr, A.J. The risks and benefits of glucocorticoid treatment for tendinopathy: A systematic review of the effects of local glucocorticoid on tendon. Semin. Arthritis Rheum. 2014, 43, 570–576. [Google Scholar] [CrossRef]
- Koester, M.C.; Dunn, W.R.; Kuhn, J.E.; Spindler, K.P. The efficacy of subacromial corticosteroid injection in the treatment of rotator cuff disease: A systematic review. J. Am. Acad. Orthop. Surg. 2007, 15, 3–11. [Google Scholar] [CrossRef]
- Cook, T.; Lowe, C.M.; Maybury, M.; Lewis, J.S. Are corticosteroid injections more beneficial than anaesthetic injections alone in the management of rotator cuff-related shoulder pain? A systematic review. Br. J. Sports Med. 2018, 52, 497–504. [Google Scholar] [CrossRef]
- Atkins, E. Physiotherapists’ experience of implementing their injection therapy skills. Physiotherapy 2003, 89, 145–157. [Google Scholar] [CrossRef]
- Bury, J.; West, M.; Chamorro-Moriana, G.; Littlewood, C. Effectiveness of scapula-focused approaches in patients with rotator cuff related shoulder pain: A systematic review and meta-analysis. Man. Ther. 2016, 25, 35–42. [Google Scholar] [CrossRef] [PubMed]
- Shire, A.R.; Stæhr, T.A.B.; Overby, J.B.; Dahl, M.B.; Jacobsen, J.S.; Christiansen, D.H. Specific or general exercise strategy for subacromial impingement syndrome–does it matter? A systematic literature review and meta analysis. BMC Musculoskelet. Disord. 2017, 18, 158. [Google Scholar] [CrossRef]
- Powell, J.K.; Costa, N.; Schram, B.; Hing, W.; Lewis, J. “Restoring that faith in my shoulder”: A qualitative investigation of how and why exercise therapy influenced the clinical outcomes of individuals with rotator cuff–related shoulder pain. Phys. Ther. 2023, 103, pzad088. [Google Scholar] [CrossRef] [PubMed]
- Docherty, S.; Harley, R.; McAuley, J.J.; Crowe, L.A.N.; Pedret, C.; Kirwan, P.D.; Siebert, S.; Millar, N.L. The effect of exercise on cytokines: Implications for musculoskeletal health: A narrative review. BMC Sports Sci. Med. Rehabil. 2022, 14, 5. [Google Scholar] [CrossRef]
- Holmgren, T.; Hallgren, H.B.; Öberg, B.; Adolfsson, L.; Johansson, K. Effect of specific exercise strategy on need for surgery in patients with subacromial impingement syndrome: Randomised controlled study. BMJ 2012, 344, e787. [Google Scholar] [CrossRef]
- Clausen, M.B.; Rathleff, M.S.; Graven-Nielsen, T.; Bandholm, T.; Christensen, K.B.; Hölmich, P.; Thorborg, K. Level of pain catastrophising determines if patients with long-standing subacromial impingement benefit from more resistance exercise: Pre-defined secondary analyses from a pragmatic randomised controlled trial (the SExSI Trial). Br. J. Sports Med. 2023, 57, 842–848. [Google Scholar] [CrossRef]
- Naranjo-Cinto, F.; Cerón-Cordero, A.-I.; Figueroa-Padilla, C.; Galindo-Paz, D.; Fernández-Carnero, S.; Gallego-Izquierdo, T.; Nuñez-Nagy, S.; Pecos-Martín, D. Real versus sham manual therapy in addition to therapeutic exercise in the treatment of non-specific shoulder pain: A randomized controlled trial. J. Clin. Med. 2022, 11, 4395. [Google Scholar] [CrossRef]
- Bradbury, K.J.; Bishop, F.L.; Yardley, L.; Lewith, G. Patients’ appraisals of public and private healthcare: A qualitative study of physiotherapy and osteopathy. J. Health Psychol. 2013, 18, 1307–1318. [Google Scholar] [CrossRef]
Range | Number | Percentage | |
---|---|---|---|
Age | |||
18–24 | 10 | 6% | |
25–34 | 63 | 39% | |
35–44 | 41 | 25% | |
45–54 | 35 | 21% | |
55–64 | 13 | 8% | |
65–74 | 1 | 1% | |
Gender | |||
Male | 79 | 48% | |
Female | 82 | 50% | |
Prefer not to answer | 2 | 1% | |
Years Qualified as Physiotherapist | |||
0–5 | 56 | 34% | |
6–10 | 23 | 14% | |
11–15 | 24 | 15% | |
16–20 | 18 | 11% | |
21–25 | 16 | 10% | |
26–30 | 13 | 8% | |
>31 | 11 | 7% | |
Number of Patients Treated Per Month | |||
<5 | 59 | 36% | |
6–10 | 69 | 42% | |
11–20 | 29 | 18% | |
21–30 | 5 | 3% | |
>30 | 1 | 1% | |
Work Setting | |||
Private Practice | 123 | 75% | |
Public Health Facility (e.g., health centre) | 9 | 5.5% | |
Elderly Care Unit | 6 | 3.6% | |
Hospital | 13 | 8% | |
Educational Institution | 8 | 5% | |
Other | 17 | 10.4% | |
Area of expertise | |||
Musculoskeletal and other | 109 | 67% | |
Musculoskeletal | 50 | 31% | |
Non-musculoskeletal | 2 | 1% | |
Not working as a clinician | 2 | 1% | |
Post-graduate education | |||
Seminar | 78 | 48% | |
Master of Science | 57 | 35% | |
None | 21 | 13% | |
PhD | 5 | 3% | |
Other | 2 | 1% |
Range | Number | Percentage | |
---|---|---|---|
Educational advice for patients | |||
Information on the pathology of rotator cuff pain, including the tissues that may be involved | 118 | 72% | |
The relationship between the occurrence of tendinopathy of the rotator cuff and the occurrence of pain | 81 | 50% | |
Risk factors, such as changing activities, lifting heavy weights, age, metabolism, etc. | 125 | 77% | |
Factors that may influence pain, such as stress levels and patient beliefs/expectations | 108 | 66% | |
Proposed physical therapy management (pathology management with physical therapy means) | 119 | 73% | |
Modifying activities and body positions (e.g., work, sports) if they are painful | 135 | 83% | |
Time stages of pathology progression and indications for imaging | 45 | 28% | |
Time stages of the development of the pathology and indications for injection treatment | 14 | 9% | |
Time stages of pathology development and indications for receiving surgical repair | 20 | 12% | |
Other | 12 | 7% | |
What exercise program would you recommend for this patient? | |||
No exercise | 0 | 0% | |
Stretching exercises | 65 | 40% | |
Shoulder isometric exercises | 116 | 71% | |
Shoulder isotonic exercises | 59 | 36% | |
Shoulder eccentric exercises | 78 | 48% | |
Shoulder isokinetic exercises | 29 | 18% | |
Exercises targeting the scapula | 106 | 65% | |
Proprioceptive exercises | 87 | 53% | |
Exercises targeting the rotator cuff | 131 | 80% | |
Exercises for the cervical and thoracic spine | 83 | 51% | |
Exercises for the motor chain of the entire upper limb | 117 | 72% | |
Aerobic exercises | 24 | 15% | |
Other | 8 | 5% | |
How do you typically instruct your patients to perform the “home” exercises? | |||
Written or printed information | 105 | 64% | |
Links to online videos or websites | 32 | 20% | |
Recorded videos on their cell phone or other device | 66 | 40% | |
Verbal instructions | 89 | 55% | |
What other management strategies would you recommend for this patient? | |||
Counseling on taking paracetamol and anti-inflammatory drugs for pain | 40 | 25% | |
Manipulations | 23 | 14% | |
Joint mobilization | 109 | 67% | |
Μassage | 95 | 58% | |
Treatment directed at the cervical/thoracic spine | 53 | 33% | |
Taping | 64 | 39% | |
Acupuncture/dry needling technique | 62 | 38% | |
Electrotherapy | 92 | 56% | |
Thermotherapy or cryotherapy | 70 | 43% | |
Rest | 49 | 30% | |
Other | 20 | 12% | |
How long would you expect a patient with reported rotator cuff pain to need physical therapy? | |||
Up to 3 weeks | 14 | 9% | |
Up to 6 weeks | 66 | 40% | |
Up to 8 weeks | 43 | 26% | |
Up to 3 months | 20 | 12% | |
Up to 6 months | 14 | 9% | |
Up to 12 months | 6 | 4% | |
How often would you review and possibly modify the exercise program of a patient with reported rotator cuff pain? | |||
I would not suggest exercise | 1 | 1% | |
Never since my original prescription | 1 | 1% | |
At least on a weekly basis | 90 | 55% | |
About every 2 weeks | 58 | 36% | |
About every 3 weeks | 11 | 7% | |
About once a month or more | 2 | 1% |
Range | Number | Percentage | |
---|---|---|---|
When formulating exercise programs, what guidelines do you typically give regarding pain during exercise? | |||
Not to hurt at all when performing exercises | 18 | 11% | |
Pain is allowed when performing exercises | 6 | 4% | |
Pain should not exceed 2–3 out of 10 on the VAS scale (0–10) | 101 | 62% | |
Pain should not exceed 6–7 out of 10 on the VAS scale (0–10) | 5 | 3% | |
The pain should subside after the end of the exercise | 26 | 16% | |
The pain should subside the next day (within 24 h) | 5 | 3% | |
When prescribing an exercise program, what guidelines do you usually give in terms of load/resistance level? | |||
Start with a light load (e.g., dumbbell) of 1–2 kg | 39 | 24% | |
Start with a load of 60–70% of 1 Repetition Maximum | 7 | 4% | |
Determine load based on symptoms (e.g., any load that results in pain no greater than 4–5 out of 10 on the VAS scale) | 72 | 44% | |
Do not determine the load based on the fatigue it causes (e.g., load that causes significant fatigue at 12 repetitions-to-failure) | 10 | 6% | |
Determine the load based on the maximum load they can lift without negatively affecting their technique when performing the exercise | 21 | 13% | |
Determine the load based on the goal they have (e.g., exercise for strength, hypertrophy, endurance) | 12 | 7% | |
When prescribing an exercise program, what instructions do you usually give in terms of reps/sets? | |||
Specific set and reps for everyone (e.g., 3 sets of 12 reps) | 7 | 4% | |
Depending on the patient’s symptoms and irritability | 122 | 75% | |
Depending on the goal (e.g., 3 × 45 s hold for isometric, 3 sets × 12 repetitions for isotonic) | 28 | 17% | |
Other | 4 | 2% | |
When prescribing an exercise regimen, what guidelines do you usually give in terms of frequency? | |||
I suggest daily execution of the exercises | 44 | 27% | |
I suggest daily execution of the exercises 3–5 times a day | 19 | 12% | |
Several times a week (3–5 times) | 24 | 15% | |
Depending on symptoms, pain, etc. | 56 | 34% | |
Depending on the goal (e.g., strengthening, hypertrophy, etc.) | 11 | 7% | |
Depending on fatigue | 2 | 1% | |
Other | 5 | 3% | |
When prescribing an exercise program, what instructions do you usually give in terms of progressing or limiting the progress of the exercises? | |||
I suggest they increase/decrease the load | 69 | 42% | |
I suggest they increase/decrease sets and reps | 44 | 27% | |
I suggest they increase/decrease the range they perform the exercise | 32 | 20% | |
Other | 16 | 10% |
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Paraskevopoulos, E.; Christakou, A.; Smythe, A.; Kapreli, E.; Papandreou, M.; Papacharalambous, C.; Pavlou, K.; Pamboris, G.M. Addressing Rotator Cuff-Related Shoulder Pain: Findings from a Greek Regional Observational Study Utilizing a Clinical Case Scenario. Clin. Pract. 2025, 15, 30. https://doi.org/10.3390/clinpract15020030
Paraskevopoulos E, Christakou A, Smythe A, Kapreli E, Papandreou M, Papacharalambous C, Pavlou K, Pamboris GM. Addressing Rotator Cuff-Related Shoulder Pain: Findings from a Greek Regional Observational Study Utilizing a Clinical Case Scenario. Clinics and Practice. 2025; 15(2):30. https://doi.org/10.3390/clinpract15020030
Chicago/Turabian StyleParaskevopoulos, Eleftherios, Anna Christakou, Andrew Smythe, Eleni Kapreli, Maria Papandreou, Charalambos Papacharalambous, Kyriakos Pavlou, and George M. Pamboris. 2025. "Addressing Rotator Cuff-Related Shoulder Pain: Findings from a Greek Regional Observational Study Utilizing a Clinical Case Scenario" Clinics and Practice 15, no. 2: 30. https://doi.org/10.3390/clinpract15020030
APA StyleParaskevopoulos, E., Christakou, A., Smythe, A., Kapreli, E., Papandreou, M., Papacharalambous, C., Pavlou, K., & Pamboris, G. M. (2025). Addressing Rotator Cuff-Related Shoulder Pain: Findings from a Greek Regional Observational Study Utilizing a Clinical Case Scenario. Clinics and Practice, 15(2), 30. https://doi.org/10.3390/clinpract15020030