Shoulder Pain

Shoulder pain is not as common as back or neck pain (7% to 26% in the general population according to Luime 2004). The most common cause of shoulder pain is thought to be disorders of the rotator cuff (Linsell 2006; Ostor 2005), Like many other problems many diagnostic terms have been used to describe rotator cuff problems (subacromial impingement syndrome, rotator cuff tendinopathy or tendinitis, partial or full rotator cuff tear, calcific tendinitis and subacromial bursitis). But the terms are not standardised (Schellingerhout 2008). The term ‘rotator cuff disease’ was proposed regardless of the cause of disorder (Buchbinder 1996; Whittle 2015). 

Recommendation: 

• Continuous or pulsed 1mhz and 3mhz have been used
  • 1mhz 1 -2.5 W/cm2
  • 3mhz 0.5-1.5 W/cm2
  • 4-15 mins (10 is average)
  • Frequency = 1x per day down to 1 x per week (3 per week is average)
  • Session 1-24 (10 is avergae) 

• Combine with =
  • Mobilisations/manipulation
  • Heat or ice
  • Home exercises (mobility and strength)

In a review in 2016 Page et al. reviewed the literature surrounding US (amongst other modalities) for rotator cuff disease.

• Positive Effect – Calcific Tendonitis:
  • Pulsed therapeutic ultrasound (three to five times a week for six weeks) when compared with placebo (inactive ultrasound therapy) for calcific tendinitis.
• At six weeks, the mean reduction in overall pain with placebo was ‐6.3 points on a 52‐point scale, and ‐14.9 points with ultrasound.
• Mean improvement in function with placebo was 3.7 points on a 100‐point scale, and 17.8 points with ultrasound.
• Ninety‐one per cent (29/32) of participants reported treatment success with ultrasound compared with 52% (15/29) of participants receiving placebo.
• Mean improvement in quality of life with placebo was 0.40 points on a 10‐point scale, and 2.60 points with ultrasound
• No participant reported adverse events.

They concluded therapeutic ultrasound may have short‐term benefits over placebo in people with calcific tendinitis.

People seeking treatment for rotator cuff problems seldom receive a single electrotherapy modality in isolation. Other physical therapy interventions such as manual therapy and exercise are commonly delivered as co‐interventions (Gebremariam 2014).

So does therapeutic ultrasound provide additional benefits over other physical therapy interventions?
Eight trials have investigated this (e.g. manual therapy, exercise, TENS, interferential current, ice or multi‐modal physical therapy)

• Calis 2011;
  • Participants: Subacromial impingement syndrome
    Intervention: Therapeutic ultrasound plus exercise plus hot pack
    Control: Exercise plus hot pack
• Results at 3 weeks:
  • Pain reduced (overall, night and on use)
  • Overall function better
  • ROM better (flex, abd, int rot, ext rot)

• Celik 2009;
  • Participants: Subacromial impingement syndrome
    Intervention: Therapeutic ultrasound plus TENS plus exercise
    Control: Placebo ultrasound plus TENS plus exercise
• Results at 3 weeks:
  • Pain reduced (overall)
  • Overall function worse
  • ROM worse (flex, abd, int rot, ext rot)
• Results at 6 weeks:
  • Pain reduced (overall)
  • Overall function better
  • ROM worse (flex, abd, int rot, ext rot)

• Clews 1987;
  • Participants: Rotator cuff tendinitis
    Intervention: Therapeutic ultrasound plus ice
    Control: Placebo ultrasound plus ice
• Results at 3 weeks:
  • Pain after strength test at 3 days improved
  • Strength (maximal isometric force production, measured in peak force) % change from baseline to 3 days improved 

• Downing 1986;
  • Participants: Supraspinatus tendinitis or subacromial bursitis
    Intervention: Therapeutic ultrasound plus exercise plus NSAID
    Control: Placebo ultrasound plus exercise plus NSAID
• Results at 4 weeks:
  • Pain no difference (used a 4‐point categorical rating scale, 0 = no pain)
  • Overall function (any vs no interference with sleep, dress, work, grooming and sports) half the group improved
  • ROM improved (abd, int rot, ext rot) worse (flex)
  • Global assessment of treatment success = “Both the patients and the physician recorded that 50% of the patients improved their overall status.”

 Kurtai Gursel 2004; 

• Participants: Supraspinatus tendinosis, subacromial bursitis, rotator cuff tear or bicipital tendinosis
  Intervention: Therapeutic ultrasound plus hot pack plus interferential current plus exercise
  Control: Sham ultrasound plus hot pack plus interferential current plus exercise

• Nykänen 1995;
  • Participants: Painful arc or supraspinatus tendinopathy/tendinitis
    Intervention: Therapeutic ultrasound plus massage plus exercises
    Control: Sham ultrasound plus massage plus exercises
• Results:
  • Pain 3-4 weeks improved (Pain Index 1‐5, higher score = worse pain)
  • Pain 4 months no difference
  • Pain 12 months no difference
  • Function 3-4 weeks slightly worse (ADL‐score 2‐10, higher score = worse function)
  • Function 4 months slightly worse
  • Function 12 months slightly worse

• Polimeni 2003;
  • Participants: Supraspinatus tendinitis or biceps tendinitis
    Intervention: Therapeutic ultrasound plus mobilisation plus exercises
    Control: Mobilisation plus exercises
• Results:
  • Function 10 days no difference (Constant‐Murley total score 0‐100, higher = better function)
  • Function 40 days no difference

• San Segundo 2008;
  • Participants: Rotator cuff tendinitis or partial rotator cuff tears
    Intervention: Therapeutic ultrasound plus exercises
    Control: Placebo ultrasound plus exercises
• Results:
  • Pain 3 weeks improved
  • Pain 5 weeks improved
  • Function 3 weeks improved (Constant‐Murley total score 0‐100, higher = better function)
  • Function 5 weeks improved

Desmeules et al. (2015)  Looked at the efficacy of therapeutic ultrasound for rotator cuff tendinopathy. In a systematic review and meta-analysis they said there was low to moderate level evidence available. Overall they said therapeutic US does not provide any benefit compared to a placebo or advice, to laser therapy or when combined to exercise. In this review, which covered articles up to 2013, only 11 published studies were included.

Analan et al.  (2015) looked at the effects of therapeutic ultrasound and exercise on pain, function, and isokinetic shoulder rotator strength of patients with rotator cuff disease. They performed a  prospective, double-blind, randomized, placebo-controlled study. Patients were treated with a ‘standard physiotherapy program’ (hot-pack, transcutaneous electrical nerve stimulation (TENS), exercises) and added US with a sham group. They found significant differences between the pre- and post-intervention UCLA Shoulder Rating Scale and Constant-Murley Shoulder Outcome scores, VAS, and external rotation (ER) peak torque 60°/second values for both the true and sham US groups. The US had yielded no additional efficacy to the physiotherapy treatment regimen of the patients with rotator cuff disease.  

It would appear that US can be effective in calcific tendonitis and is better combined with other treatments overall. Some treatments seem to be better with US alongside whilst other seem to do worse.