Margit Kooijman

26 Background Shoulder complaints are the most common complaints of the extremities in an average physiotherapy practice; 9.8% of all patients present with this type of problem 1 . Low back pain and neck pain are the only complaints for which a general practitioner (GP) refers more patients to the physiotherapist; 7.3% of all referrals to a physiotherapist are made for shoulder complaints 2 . Studies report unfavourable outcomes in many patients 3-6 , high costs in terms of secondary care and sick leave 7 and frequent occurrence in the workplace 8 . Therefore, shoulder conditions involve a considerable burden for the individual and the society. Shoulder complaints can be roughly divided into problems with the glenohumeral joint (frozen shoulder, osteoarthritis) shoulder instability, acromioclavicular or sternoclavicular complaints, cervical or cervicothoracic dysfunction and problems with structures in the subacromial space. It has been estimated that approximately 44-80% of all shoulder complaints originate from these anomalies of structures in the subacromial space 9,10 . This space contains the tendons of the rotator cuff muscles and two bursae. Entrapment or inflammation of these structures leads to a restricted range of motion and pain. Although these complaints are described as shoulder syndromes, there is lack of consensus on the diagnostic criteria and on the best approach to management 11- 14 Incidence and prevalence of shoulder conditions have been identified but there are no such estimates for shoulder syndromes 14 . In addition, a recent systematic review of the literature indicates that many studies on the management of impingement syndrome are deficient in detailed demographic information, as well as information on previous medical treatment such as corticosteroid injections or (non-) steroidal anti- inflammatory drugs, previous physiotherapy and even the duration of the symptoms at the start of treatment 14 . The current study provides this information for a large group of patients who consulted their general practitioner (GP) or physiotherapist for these complaints. As referred to above, there is debate on the best treatment methods for patients with shoulder syndromes. Dorrestijn et al. 11 and Kromer et al. 15 showed that so far, there is no evidence indicating whether surgical treatment or conservative treatment has a better outcome for patients with shoulder syndromes. Therefore, it is suggested that patients should be treated conservatively before surgical intervention is considered 15 . There is a Dutch guideline for (general) shoulder complaints for GPs that suggests a stepwise approach of advice, analgesia and referral for physiotherapy 9 . There also is a short guideline available for physiotherapists. This is based partly on scientific evidence and partly on best practice because the content of physiotherapy treatment, as part of conservative treatment, is still under discussion 16 . This results in a variable number of patients (20 -79%) that respond well to physiotherapy 10 . In order to improve treatment, knowledge of current treatment methods is indispensable but as yet, it is not adequately available.