Progressive exercise compared with best practice advice, with or without corticosteroid injection, for the treatment of patients with rotator cuff disorders (GRASP): a multicentre, pragmatic, 2×2 factorial, randomised controlled trial
Four pages on PainSci cite Hopewell 2021: 1. Guide to Repetitive Strain Injuries 2. Complete Guide to Frozen Shoulder 3. What Works for Chronic Pain? 4. STUDY: Exercise, Steroids, and Shoulder Pain That Might Be Tendinitis (Member Post)
PainSci notes on Hopewell 2021:
The GRASP trial is a study of steroids versus exercise for (mainly) shoulder tendinitis, and it basically showed that there are no major differences. They are both equally effective and modest, or equally ineffective. Unsurprisingly, steroids are more helpful in the short term.
This is a large, complex trial with some glaring flaws but also a lot of useful data. I have a large blog post that really digs into it for almost 3000 words. Big study, big analysis! See STUDY: Exercise, Steroids, and Shoulder Pain That Might Be Tendinitis (Member Post). But here are the key takeaways:
- Our poor understanding of what’s actually wrong with these shoulders is a serious limitation. It makes the whole GRASP trial more like a REACH.
- As just mentioned, the lack of a more neutral comparison really makes it hard to know whether steroids and exercise are equally effective… or equally ineffective.
- Maybe “rotator cuff disorders” are generally invincible! It is a tough problem, no doubt about it.
- Nevertheless, it would be reasonable to use this citation to support advising people not to bother with any kind of care for shoulder pain.
- Exercise and steroid injections are two of the very most popular treatment options for shoulder. If they don’t work, it’s not like there’s a bunch of other strong candidates waiting in the wings.
- Some people in every group did better than others, of course. The results were an average. But, as always, good luck identifying those “responders” in advance!
original abstract †Abstracts here may not perfectly match originals, for a variety of technical and practical reasons. Some abstacts are truncated for my purposes here, if they are particularly long-winded and unhelpful. I occasionally add clarifying notes. And I make some minor corrections.
BACKGROUND: Corticosteroid injections and physiotherapy exercise programmes are commonly used to treat rotator cuff disorders but the treatments' effectiveness is uncertain. We aimed to compare the clinical effectiveness and cost-effectiveness of a progressive exercise programme with a single session of best practice physiotherapy advice, with or without corticosteroid injection, in adults with a rotator cuff disorder.
METHODS: In this pragmatic, multicentre, superiority, randomised controlled trial (2×2 factorial), we recruited patients from 20 UK National Health Service trusts. We included patients aged 18 years or older with a rotator cuff disorder (new episode within the past 6 months). Patients were excluded if they had a history of significant shoulder trauma (eg, dislocation, fracture, or full-thickness tear requiring surgery), neurological disease affecting the shoulder, other shoulder conditions (eg, inflammatory arthritis, frozen shoulder, or glenohumeral joint instability), received corticosteroid injection or physiotherapy for shoulder pain in the past 6 months, or were being considered for surgery. Patients were randomly assigned (centralised computer-generated system, 1:1:1:1) to progressive exercise (≤6 sessions), best practice advice (one session), corticosteroid injection then progressive exercise, or corticosteroid injection then best practice advice. The primary outcome was the Shoulder Pain and Disability Index (SPADI) score over 12 months, analysed on an intention-to-treat basis (statistical significance set at 1%). The trial was registered with the International Standard Randomised Controlled Trial Register, ISRCTN16539266, and EuDRACT, 2016-002991-28.
FINDINGS: Between March 10, 2017, and May 2, 2019, we screened 2287 patients. 708 patients were randomly assigned to progressive exercise (n=174), best practice advice (n=174), corticosteroid injection then progressive exercise (n=182), or corticosteroid injection then best practice advice (n=178). Over 12 months, SPADI data were available for 166 (95%) patients in the progressive exercise group, 164 (94%) in the best practice advice group, 177 (97%) in the corticosteroid injection then progressive exercise group, and 175 (98%) in the corticosteroid injection then best practice advice group. We found no evidence of a difference in SPADI score between progressive exercise and best practice advice when analysed over 12 months (adjusted mean difference -0·66 [99% CI -4·52 to 3·20]). We also found no evidence of a difference between corticosteroid injection compared with no injection when analysed over 12 months (-1·11 [-4·47 to 2·26]). No serious adverse events were reported.
INTERPRETATION: Progressive exercise was not superior to a best practice advice session with a physiotherapist in improving shoulder pain and function. Subacromial corticosteroid injection provided no long-term benefit in patients with rotator cuff disorders.
FUNDING: UK National Institute for Health Research Technology Assessment Programme.
This page is part of the PainScience BIBLIOGRAPHY, which contains plain language summaries of thousands of scientific papers & others sources. It’s like a highly specialized blog. A few highlights:
- Common interventional procedures for chronic non-cancer spine pain: a systematic review and network meta-analysis of randomised trials. Wang 2025 BMJ.
- Gabapentinoids and Risk of Hip Fracture. Leung 2024 JAMA Netw Open.
- Classical Conditioning Fails to Elicit Allodynia in an Experimental Study with Healthy Humans. Madden 2017 Pain Med.
- Topical glyceryl trinitrate (GTN) and eccentric exercises in the treatment of mid-portion achilles tendinopathy (the NEAT trial): a randomised double-blind placebo-controlled trial. Kirwan 2024 Br J Sports Med.
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