A Systematic Review of Clinical Practice Guidelines on the Diagnosis and Management of Various Shoulder Disorders

Arch Phys Med Rehabil. 2023 Oct 11:S0003-9993(23)00584-1. doi: 10.1016/j.apmr.2023.09.022. Online ahead of print.


Objective: To perform a systematic review of clinical practice guidelines (CPGs) covering the management of common shoulder disorders.

Data sources: A systematic search of CPGs on specific shoulder disorders was conducted up to August 2022 in relevant databases.

Study selection: Twenty-six CPGs on rotator cuff (RC) tendinopathy, RC tear, calcific tendinitis, adhesive capsulitis, glenohumeral (GH) instability, GH osteoarthritis, or acromioclavicular disorders published from January 2008 onward were screened and included.

Data extraction: CPGs methodological quality was assessed with the AGREE II checklist. All recommendations from CPGs were extracted and categorized by shoulder disorder and care components (evaluation, diagnostic imaging, medical, rehabilitation, and surgical treatments). After semantic analysis of the terminology, recommendations for each shoulder disorders were classified by 2 reviewers into "recommended," "may be recommended," or "not recommended." Disagreements were resolved by discussion until reviewers reached consensus.

Data synthesis: Only 12 CPGs (46%) were of high quality with major limitations related to the applicability and editorial independence of the guidelines. The initial evaluation of shoulder pain should include patient's history, subjective evaluation focused on red flags, and clinical examination. Magnetic resonance imaging is usually not recommended to manage early shoulder pain, and recommendations for X-rays are conflicting. Acetaminophen, oral non-steroidal anti-inflammatory drugs, and rehabilitation including exercises were recommended or may be recommended to treat all shoulder pain disorders. Guidelines on surgical management recommendations differed; for example, 6 CPGs reported that acromioplasty was recommended or may be recommended in chronic RC tendinopathy, whereas 4 CPGs did not recommend it.

Conclusions: Recommendations vary for diagnostic imaging, conservative vs surgical treatment to manage shoulder pain, although several care components are consensual. The development of evidence-based, rigorous CPGs with a valid methodology and transparent reporting is warranted to improve overall shoulder pain care.

Keywords: Clinical practice guidelines; Evaluation; Management; Recommendations; Rehabilitation; Shoulder.

Publication types

  • Review