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Effectiveness of conservative interventions including exercise, manual therapy and medical management in adults with shoulder impingement: a systematic review and meta-analysis of RCTs
  1. Ruedi Steuri1,2,
  2. Martin Sattelmayer2,3,
  3. Simone Elsig2,3,
  4. Chloé Kolly2,3,
  5. Amir Tal1,
  6. Jan Taeymans1,4,
  7. Roger Hilfiker2,3
  1. 1 Department of Health, Bern University of Applied Sciences, Berne, Switzerland
  2. 2 Department of Physiotherapy, University of Applied Sciences Western Switzerland, Leukerbad, Switzerland
  3. 3 School of Health Sciences, HES-SO Valais-Wallis, University of Applied Sciences and Arts Western Switzerland Valais, Leukerbad, Switzerland
  4. 4 Faculty of Sport and Rehabilitation Science, Vrije Universiteit Brussel, Brussels, Belgium
  1. Correspondence to Roger Hilfiker, School of Health Sciences, HES-SO Valais-Wallis, University of Applied Sciences and Arts Western Switzerland Valais, Rathausstrasse 8, Leukerbad 3954, Switzerland; roger.hilfiker{at}


Objective To investigate the effectiveness of conservative interventions for pain, function and range of motion in adults with shoulder impingement.

Design Systematic review and meta-analysis of randomised trials.

Data sources Medline, CENTRAL, CINAHL, Embase and PEDro were searched from inception to January 2017.

Study selection criteria Randomised controlled trials including participants with shoulder impingement and evaluating at least one conservative intervention against sham or other treatments.

Results For pain, exercise was superior to non-exercise control interventions (standardised mean difference (SMD) −0.94, 95% CI −1.69 to −0.19). Specific exercises were superior to generic exercises (SMD −0.65, 95% CI −0.99 to −0.32). Corticosteroid injections were superior to no treatment (SMD −0.65, 95% CI −1.04 to −0.26), and ultrasound guided injections were superior to non-guided injections (SMD −0.51, 95% CI −0.89 to −0.13). Nonsteroidal anti-inflammatory drugs (NSAIDS) had a small to moderate SMD of −0.29 (95% CI −0.53 to −0.05) compared with placebo. Manual therapy was superior to placebo (SMD −0.35, 95% CI −0.69 to −0.01). When combined with exercise, manual therapy was superior to exercise alone, but only at the shortest follow-up (SMD −0.32, 95% CI −0.62 to −0.01). Laser was superior to sham laser (SMD −0.88, 95% CI −1.48 to −0.27). Extracorporeal shockwave therapy (ECSWT) was superior to sham (−0.39, 95% CI −0.78 to –0.01) and tape was superior to sham (−0.64, 95% CI −1.16 to −0.12), with small to moderate SMDs.

Conclusion Although there was only very low quality evidence, exercise should be considered for patients with shoulder impingement symptoms and tape, ECSWT, laser or manual therapy might be added. NSAIDS and corticosteroids are superior to placebo, but it is unclear how these treatments compare to exercise.

  • Shoulder Impingement
  • Conservative
  • Pain
  • Meta-Analysis
  • Systematic Review

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:

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  • Contributors RS, RH, AT, JT conceived the study and wrote the protocol. RS, RH, SE, CK and MS selected studies and extracted data. RS, RH, JT and MS analysed the data. All authors interpreted the data. RS wrote the first draft of the manuscript and all authors contributed to the writing of the final version.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Correction notice This paper has been amended since it was published Online First. Owing to a scripting error, some of the publisher names in the references were replaced with ‘BMJ Publishing Group’. This only affected the full text version, not the PDF. We have since corrected these errors and the correct publishers have been inserted into the references.

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