The Clinical Challenge of Subacromial Pain
Subacromial Pain Syndrome (SAPS), formerly widely known as shoulder impingement syndrome, remains one of the most frequent musculoskeletal presentations in orthopedic and physiotherapy clinics. Despite its prevalence, the optimal management strategy involves navigating a complex matrix of treatment options, primarily centering on exercise therapy and corticosteroid injections. A pivotal 2021 study published in the British Journal of Sports Medicine by Roddy et al. sought to clarify two specific uncertainties: the mode of exercise delivery and the necessity of imaging guidance for injections.
For the practicing physiotherapist, understanding the nuances of delivery—specifically the value of supervision versus independent management, and the technical requirements of injection therapy—is vital for evidence-based practice and resource allocation.
Study Design: A Robust Factorial RCT
The research team conducted a 2×2 factorial randomised controlled trial involving 256 adults diagnosed with SAPS. This rigorous design allowed the researchers to simultaneously evaluate two separate interventions within the same cohort. Participants were randomised into one of four distinct treatment groups:
- Ultrasound-guided injection + Physiotherapist-led exercise
- Ultrasound-guided injection + Exercise leaflet
- Unguided injection + Physiotherapist-led exercise
- Unguided injection + Exercise leaflet
The primary outcome measure was the Shoulder Pain and Disability Index (SPADI), assessed at 6 weeks, 6 months, and 12 months. This long-term follow-up is particularly relevant for establishing the durability of treatment effects.
The Value of Supervision: Physio-Led Exercise vs. Leaflets
One of the study’s most significant findings for our profession validates the role of the physiotherapist in patient recovery. The results demonstrated that physiotherapist-led exercise resulted in greater improvement in total SPADI scores compared to receiving an exercise leaflet alone, particularly at the 6-month mark (adjusted mean difference -8.23).
While self-management strategies are often touted for their cost-effectiveness, this data suggests that the therapeutic alliance, progression, and feedback provided during supervised sessions translate to superior clinical outcomes in pain and function. For patients with SAPS, the “prescribe and forget” model using generic leaflets appears inferior to active professional engagement.
Injection Accuracy: Is Ultrasound Guidance Necessary?
The second arm of the study addressed a contentious debate in orthopedic medicine: does the precision of ultrasound guidance improve the efficacy of subacromial corticosteroid injections? The results indicated no significant differences in pain or function between the ultrasound-guided and unguided injection groups at 6 weeks, 6 months, or 12 months.
For clinicians, this suggests that unguided injections—relying on anatomical landmarks—are as clinically effective as their image-guided counterparts for this specific condition. This finding has substantial implications for reducing costs and waiting times associated with accessing radiology services.
Clinical Implications for Physiotherapists
The Roddy et al. trial provides a clear directive for optimizing SAPS care pathways. The data supports a model where resources are shifted away from expensive imaging-guided procedures and toward supervised rehabilitation. The winning combination for long-term improvement appears to be accessible, unguided injections (when indicated for pain control) paired with robust, physiotherapist-led exercise programs.
References
Roddy, E., Ogollah, R. O., Oppong, R., Zwierska, I., Datta, P., Hall, A., Hay, E., Jackson, S., Jowett, S., Lewis, M., Shufflebotham, J., Stevenson, K., van der Windt, D. A., Young, J., & Foster, N. E. (2021). Optimising outcomes of exercise and corticosteroid injection in patients with subacromial pain (impingement) syndrome: a factorial randomised trial. British Journal of Sports Medicine, 55(5), 262–271.
