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Shoulder Pain - Injections? Surgery? Where do I start?

Published: May 13, 2021


Shoulder pain is the third most common musculoskletal problem in general population (behind LBP and neck pain) and has a lifetime Prevalence of up to 70%. Shoulder pain often can be ongoing as reported rates of up to 50% of shoulder pain lasting/reoccurring after 1 year.

Often, individuals come into the clinic and question about whether an ultrasound is needed or if alternative treatments, such as injections or surgery, should be implemented. We have searched through some of the evidence and provided a simple summary below.


Diagnostic Ultrasound

  • Calcific Tendinopathy (Sansone 2015)
    • 1 in 3 symptomatic shoulders have a positive ultrasound
    • 1 in 7 asymptomatic shoulders have a positive ultrasound
  • Asymptomatic male shoulders (Girish 2011)

    • Shoulder abnormalities were found in 96% of subjects
    • Bursal thickening were found in 78% (40/51) shoulders

Take home massage:

  • A lot of the time a shoulder ultrasound will show ‘abnormalities’ even if there is no pain
  • Pain is a poor indicator of structural abnormalities


Cortisol steroid injections

  • Cortisone injections vs. Local Anesthetic (Maybury 2012)
    • Nil difference in outcomes after 8 weeks, up to 52 weeks.
  • Cortisone injections vs. Exercise only (Conaghan 2009)

    • Nil difference at Week 8 (Weeks 1-5 small benefit Cortisone>Exercise)

Take home massage:

  • Cortisone injections have not been shown to be better than exercise in these studies, especially in long term follow ups



  • Surgery vs. Physiotherapy – 5-year follow-up (Ketola 2013)
    • No difference in outcomes – Shoulder impingement syndrome.
  • Decompression vs. Arthroscopy – 12-month follow-up (CSAW study 2018)

    • No difference in outcomes

Take home massage:

  • No difference concluded with Surgery vs Physio for shoulder impingement injuries



  • Physiotherapy for atraumatic Full-thickness rotator cuff tears – 2 year follow up
    • 75% did not require surgery at follow-up
    • Most of the 25% that elected for surgery did so before the 12-week mark
    • Patients who committed to physiotherapy for longer than 12 weeks are most likely to avoid surgery.

Take home massage:

  • Sticking to an exercise program will likely reduce the implications for surgery



Final note

There are shoulder injuries that require alternative investigations and treatments other than Physiotherapy but a lot of the time sticking with Physiotherapy and a structured exercise program will have great outcomes.

If unsure whether your shoulder injury will require further investigations or treatments such as surgery or injects come see us in our clinic.