Shoulder pain remains one of the most prevalent musculoskeletal complaints in primary care, often leading to significant functional limitations and healthcare expenditures. For physiotherapists, the clinical decision-making process frequently involves determining whether a patient is better served by immediate symptom relief via corticosteroid injection or a structured, active rehabilitation program. A new Randomized Controlled Trial (RCT), the SIX-Shoulder Study, published in Family Practice (Oct 2025), sheds light on the long-term economic and clinical value of these opposing interventions.
The Economic Burden of Shoulder Pathology
While clinical guidelines generally recommend either corticosteroid injections or exercise therapy, the long-term comparative cost-effectiveness has remained ambiguous. Injections are often viewed as a low-cost, time-efficient intervention in the short term. Conversely, physiotherapist-led exercise therapy involves multiple sessions and higher direct costs initially. However, determining value requires analyzing not just the sticker price, but the Quality-Adjusted Life Years (QALY) gained over time.
Methodology: The SIX-Shoulder Protocol
Researchers conducted an RCT in Dutch primary care settings involving 183 participants presenting with a new episode of shoulder pain. The cohort was randomized into two distinct groups:
- Injection Group (n=91): Received a corticosteroid injection.
- Exercise Group (n=92): Participated in a 12-week physiotherapist-led exercise therapy program.
Participants were monitored over a 12-month period using questionnaires at baseline, 6 weeks, and 3, 6, 9, and 12 months. The primary outcome measure was the incremental cost per QALY gained, analyzed via the Incremental Cost-Effectiveness Ratio (ICER).
Analyzing Costs and Quality of Life
The results provided a nuanced view of healthcare value. Over the 12-month follow-up, the exercise therapy group incurred higher incremental costs (€428; 95% CI: -1825 to 2682) compared to the injection group. However, the exercise group also demonstrated a gain in QALY (0.02957).
This resulted in an ICER of €14,489 per QALY gained. In health economics, an intervention is generally considered cost-effective if the cost per QALY falls below a certain willingness-to-pay (WTP) threshold. At a WTP threshold of €50,000, the analysis showed a 70% probability that exercise therapy is cost-effective compared to corticosteroid injections.
Clinical Implications for Physiotherapists
For the clinician, these findings reinforce the value of active rehabilitation. While corticosteroid injections may offer a lower upfront cost, they do not necessarily provide the best long-term value regarding patient quality of life. The data suggests that despite the higher initial resource intensity of a 12-week exercise program, the resulting health utility justifies the investment.
Physiotherapists can use this evidence to advocate for exercise therapy as a primary intervention. It supports the narrative that “cheaper” interventions (injections) are not always the most economically sound choice when patient quality of life is the metric of success.
References
Versloot, A. H. C., Toy, M., Schiphof, D., Bindels, P., Ottenheijm, R. P. G., de Graaf, M., van der Windt, D. A., van Ochten, J. M., Koes, B. W., & Runhaar, J. (2025). Cost-effectiveness of a corticosteroid injection versus exercise therapy for shoulder pain in general practice (SIX-Shoulder Study): a randomized controlled trial. Family Practice.
https://pubmed.ncbi.nlm.nih.gov/41243275/
