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Exercise, steroids, and shoulder pain that might be tendinitis [STUDY, PREMIUM]

 •  • by Paul Ingraham
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Weekly nuggets of pain science news and insight, usually 100-300 words, with the occasional longer post. The blog is the “director’s commentary” on the core content of PainScience.com: a library of major articles and books about common painful problems and popular treatments. See the blog archives or updates for the whole site.
Photo of a woman with frozen shoulder, holding her shoulder, in pain.

I just keep hearing happy stories about corticosteroid injections lately. I am starting to want one myself. Almost anywhere will do, really.

I have an elderly friend who has — I am not making this up — been injected about a dozen times in various arthritic joints over the last couple years, with near perfect and long-term relief in every case. And indeed, she does seem spry! This story startled me, because I am used to thinking of steroid injections as an unpredictable and ephemeral treatment, a needle that is unlikely to move the needle for more than a few weeks at a time. Or maybe just a few days. Or not at all.

A happy steroid anecdote for a frozen shoulder case

I lean towards pessimism about steroids for the pain of frozen shoulder, which is a cranky honey badger of a pathology. But get a load of this good news report from rehab expert Greg Lehman on July 14:

Frozen shoulder update! Feeling amazing. Had a shot 4 weeks ago and I now have almost 90% full ROM. Golf doesn’t hurt and more importantly I can give the finger vigorously to drivers who blow stop signs near my kids with impunity and no pain.

Great! But will it last? Greg had already waited a few weeks to report his success, no doubt wary of declaring victory prematurely, but I made a point of checking in several weeks further on… and he’s still in good shape. And skateboarding! So it’s still great. As anyone who has had frozen shoulder knows, arm flailing is verboten with that condition.

But did he really need that shot? Could he have gotten to the same happy place with exercise?

Or maybe just a chat with a physiotherapist? (Or himself, since he’s plenty knowledgeable?)

A major new study has compared exactly those options. Thoroughly. And I will explore it thoroughly — more thoroughly than usual. Big study, big analysis.

The “GRASP” trial: Hopewell et al. on steroids vs. exercise

This post is mostly about the “GRASP” trial, by Hopewell et al. (See also physical therapist Adam Meakin’s analysis.) GRASP is one of those forced acronyms, in this case awkwardly representing Getting it Right: Addressing Shoulder Pain. What are the odds I am going to make fun of how they aren’t “getting it right” before this is over? If you’re new here, the answer is all of the odds.

Mostly a fine study, though.

Steroid injections and exercise are both used to treat pain arising from the small muscles and tendons around the shoulder, the “rotator cuff” (not the same as Greg’s frozen shoulder, although there’s some overlap). No one really knows how well either approach works.

So Hopewell et al. thoroughly compared them in the huge GRASP trial. This is a downright enormous study for this field: hundreds of people from around the United Kingdom, with a full year of follow-up. Impressive. And perhaps not surprising for the The Lancet, an important journal.

This was a “superiority” trial, which attempts to determine which of two treatments is more efficacious. It’s debatable whether this is the right kind of trial for the job, but that’s what they chose. I hope they got it right!

Rotator cuff disorders are a big deal… maybe?

From the introduction to the study:

Disorders of the rotator cuff are the most common cause [of shoulder pain], accounting for 70% of cases. Rotator cuff disorders are often associated with substantial and persistent disability and pain and approximately half of patients continue to have pain or functional limitations for up to 2 years.

That “70% of all cases” claim is important setup — shoot, it’s literally the raison d’etre for this ginormous trial — so it should probably be supported by some good data, right? Unfortunately, their citation (to Mitchell 2005) is just garbage for this purpose: it’s a fifteen-year-old topic primer for family docs that doesn’t even adequately define rotator cuff disorders, let alone credibly establish their prevalence (not even by citing another paper).

I do not dispute that there’s a lot of shoulder pain out there, and a bunch of it could be classified as “rotator cuff disorders,” but a sloppy prevalence citation like that is worrisome. Definitely not “getting it right” so far…

The analysis continues for premium subscribers only

This is about the one third point of a premium post. If you want to know what the GRASP trial did and didn’t get right, you’ll need pay for a premium newsletter subscription to read more. The whole thing is about 2200 words — really very large for one of my posts! It’s destined to be part of a book about shoulder pain someday. This is how the sausage gets made: one post at a time.

Lots of good stuff still to come in this post…

  • And what are rotator cuff “disorders” anyway? The definition leaves quite a lot to be desired.
  • GRASP is a tender tendon study, mainly: tendinitis. Might have been better to just say that, GRASP!
  • The treatment tests: did they or did they not actually test exercise?
  • GRASPing at conclusions
  • Denouement: an example of steroids failing