Physiotherapeutische Untersuchung und Behandlung von Muskel-Sehnen-assoziierten Schulterschmerzen

Zusammenfassung

Hintergrund

Seit November 2024 können verschiedene Schulterdiagnosen auf der Basis der Blankoverordnung behandelt werden. Physiotherapeut*innen können die Art des Heilmittels und die Frequenz frei wählen. Dafür wären geeignete Praxisleitlinien hilfreich, um diesen Prozess transparenter zu gestalten und einen Entscheidungskorridor zu bieten. Leitlinien der Arbeitsgemeinschaft wissenschaftlicher medizinischer Fachgesellschaften (AWMF) geben zwar Handlungsanweisungen bezüglich empfohlener und nicht empfohlener Maßnahmen, äußern sich aber weder zur physiotherapeutischen Untersuchung noch zu genauen Parametern für die Behandlung.

Ziel

Untersuchung der Fragestellung: Welche Handlungsempfehlungen ergeben sich für die physiotherapeutische Untersuchung und Behandlung von Patient*innen mit Schulterbeschwerden?

Methode

Um eine Grundlage für die Entwicklung einer deutschsprachigen physiotherapeutischen Praxisleitlinie zu schaffen, wurden von einem Team aus klinisch und wissenschaftlich tätigen Physiotherapeut*innen englischsprachige Praxisleitlinien zu Muskel-Sehnen-assoziierten Schulterschmerzen übersetzt, zusammengefasst und kommentiert. Textpassagen und Empfehlungen aus der Literatur wurden von jeweils mindestens 2 Personen pro Leitlinie in ein gemeinsames Dokument überführt und in 4 Konsensuskonferenzen zusammengeführt und auf Aktualisierungsbedarf überprüft.

Ergebnisse

Es wurden 8 internationale Leitlinien analysiert. Dabei wurden für die Anamnese und körperliche Untersuchung folgende Ziele identifiziert: (1) Erkennen von Red Flags, (2) Erkennen von klinischen Mustern und Abgrenzung verschiedener Schulterpathologien, (3) Einschätzung der Beeinträchtigung auf Funktions- und Partizipationsebene und (4) Auswahl der ersten Behandlung. Für die Behandlung ergaben sich die folgenden physiotherapeutischen Ziele: (1) Minimierung von Schmerzen und Reduktion akuter Entzündungszeichen, (2) Verbesserung der Beweglichkeit, Kraft, Stabilität und der Körperhaltung, (3) Förderung des Selbstmanagements, (4) Reduktion von psychosozialen Risikofaktoren und Förderung der Partizipation. Zu diesen Zielen wurden aus der Literatur Empfehlungen abgeleitet oder bei fehlenden Informationen auf eine Evidenzlücke hingewiesen.

Schlussfolgerungen

Die Ergebnisse dieser Arbeit dienen als Darstellung der aktuellen Evidenz zu internationalen Praxisleitlinien, als Grundlage für systematische Übersichtsarbeiten zu den identifizierten Themen, die dann die Erstellung einer Praxisleitlinie ermöglichen.

Abstract

Background

Since November 2024, various shoulder diagnoses can be treated on the basis of a “blank prescription”. Physiotherapists are free to choose the type of treatment and frequency. Suitable practice guidelines would be helpful here to make this process more transparent and provide a decision-making corridor. Although guidelines from the Association of Scientific Medical Societies in Germany (AWMF) provide instructions regarding recommended and non-recommended measures, they do not comment on the physiotherapy examination or the exact parameters for treatment.

Aim

To evaluate the question: What recommendations can be made for the physiotherapeutic examination and treatment of patients with shoulder complaints?

Method

In order to create a basis for the development of a German-language physiotherapy practice guideline, a team of clinically and scientifically active physiotherapists translated, summarised and commented on English-language practice guidelines on muscle-tendon-associated shoulder pain. Text passages and recommendations from the literature were transferred into a joint document by at least 2 people per guideline and summarised in 4 consensus conferences and reviewed for the need for updates.

Results

Eight international guidelines were analysed. The following objectives were identified for the medical history and physical examination: (1) recognition of red flags, (2) recognition of clinical patterns and differentiation of various shoulder pathologies, (3) assessment of impairment at the functional and participation level and (4) selection of initial treatment. The following physiotherapy goals were set for the treatment: (1) minimisation of pain and reduction of acute signs of inflammation, (2) improvement of mobility, strength, stability and posture, (3) promotion of self-management, (4) reduction of psychosocial risk factors and promotion of participation. For these objectives, recommendations were derived from the literature or, in the absence of information, a gap in the evidence was pointed out.

Conclusions

The results of this study serve as a presentation of the current evidence on international practice guidelines, as a basis for systematic reviews on the identified topics, which in turn enable the creation of a practice guideline.

Schlüsselwörter

Schulterschmerzen - Rotatorenmanschette - Praxisleitlinie - Physiotherapie - Impingementsyndrom

Key words

shoulder pain - rotator cuff - practice guideline - physiotherapy - impingement syndrome

Publikationsverlauf

Eingereicht: 31. März 2025

Angenommen: 16. Juli 2025

Artikel online veröffentlicht:
01. September 2025

• Literatur

• 1 Lucas J, van Doorn P, Hegedus E. et al. A systematic review of the global prevalence and incidence of shoulder pain. BMC Musculoskelet Disord 2022; 23: 1073
• 2 Klauber J, Günster C, Gerste B. et al. Versorgungs-Report 2015/2016. Schwerpkt Kinder Jugendliche. Stuttgart: Schattauer; 2016
• 3 Kooijman M, Swinkels I, Dijk C van. et al. Patients with shoulder syndromes in general and physiotherapy practice: an observational study. BMC Musculoskelet Disord 2013; 14: 128
• 4 Artus M, Windt DA van der, Afolabi EK. et al. Management of shoulder pain by UK general practitioners (GPs): a national survey. BMJ Open 2017; 7: e015711
• 5 Kromer TO, Kohl M, Bastiaenen CHG. Factors predicting long-term outcomes following physiotherapy in patients with subacromial pain syndrome: a secondary analysis. BMC Musculoskelet Disord 2024; 25: 579
• 6 Walker-Bone K, Palmer KT, Reading I. et al. Prevalence and impact of musculoskeletal disorders of the upper limb in the general population. Arthritis Care Res 2004; 51: 642-651
• 7 Dhillon KS. Subacromial Impingement Syndrome of the Shoulder: A Musculoskeletal Disorder or a Medical Myth?. Malays Orthop J 2019; 13: 1-7
• 8 Barrett E, Larkin L, Caulfield S. et al. Physical Therapy Management of Nontraumatic Shoulder Problems Lacks High-Quality Clinical Practice Guidelines: A Systematic Review with Quality Assessment Using the AGREE II Checklist. J Orthop Sports Phys Ther 2021; 51: 63-71
• 9 Lowry V, Lavigne P, Zidarov D. et al. A Systematic Review of Clinical Practice Guidelines on the Diagnosis and Management of Various Shoulder Disorders. Arch Phys Med Rehabil 2024; 105: 411-426
• 10 Brouwers MC, Kho ME, Browman GP. et al. AGREE II: advancing guideline development, reporting and evaluation in health care. Can Med Assoc J 2010; 182: E839-E842
• 11 American Academy of Orthopaedic Surgeons, Hrsg. Management of Rotator Cuff Injuries Evidence-Based Clinical Practice Guideline. 2020 Zugriff am 04. August 2025 unter: www.aaos.org/globalassets/quality-and-practice-resources/rotator-cuff/rotator-cuff-cpg-final-12-20-19.pdf
• 12 Bussières AE, Taylor JAM, Peterson C. Diagnostic imaging practice guidelines for musculoskeletal complaints in adults-an evidence-based approach-part 3: spinal disorders. J Manipulative Physiol Ther 2008; 31: 33-88
• 13 Small KM, Adler RS. Expert Panel on Musculoskeletal Imaging. et al. ACR Appropriateness Criteria® Shoulder Pain-Atraumatic. J Am Coll Radiol JACR 2018; 15: S388-S402
• 14 Hanchard NCA, Cummins J, Jeffries C. Evidence-based clinical guidelines for the diagnosis, assessment and physiotherapy management of shoulder impingement syndrome. The Chartered Society of Physiotherapy;. 2004
• 15 Hopman. et al. Clinical Practice Guidelines for the Management of Rotator Cuff Syndrome in the Workplace. 2013 Zugriff am 04. August 2025 unter: https://rcs.med.unsw.edu.au/sites/default/files/rcs/page/RotatorCuffSyndromeGuidelines.pdf
• 16 Lafrance S, Charron M, Roy J-S. et al. Diagnosing, Managing, and Supporting Return to Work of Adults With Rotator Cuff Disorders: A Clinical Practice Guideline. J Orthop Sports Phys Ther 2022; 52: 647-664
• 17 Raizman NM, Kane SF. AAOS Appropriate Use Criteria: Management of Rotator Cuff Pathology. Am Acad Orthop Surg 2022; 30: e808-e810 Zugriff am 04. August 2025 unter: www.aaos.org/globalassets/quality-and-practice-resources/rotator-cuff/rcauc.pdf
• 18 Yu H, Côté P, Wong JJ. et al. Noninvasive management of soft tissue disorders of the shoulder: A clinical practice guideline from the Ontario Protocol for Traffic Injury Management (OPTIMa) collaboration. Eur J Pain Lond Engl 2021; 25: 1644-1667
• 19 Leonardi M, Lee H, Kostanjsek N. et al. 20 Years of ICF – International Classification of Functioning, Disability and Health: Uses and Applications around the World. Int J Environ Res Public Health 2022; 19: 11321
• 20 Steiner WA, Ryser L, Huber E. et al. Use of the ICF model as a clinical problem-solving tool in physical therapy and rehabilitation medicine. Phys Ther 2002; 82: 1098-1107
• 21 Germann G, Wind G, Harth A. The DASH(Disability of Arm-Shoulder-Hand) Questionnaire – a new instrument for evaluating upper extremity treatment outcome. Handchir Mikrochir Plast Chir Organ Deutschsprachigen Arbeitsgemeinschaft Handchir Organ Deutschsprachigen Arbeitsgemeinschaft Mikrochir Peripher Nerven Gefasse Organ V 1999; 31: 149-152
• 22 Angst F, Goldhahn J, Pap G. et al. Cross-cultural adaptation, reliability and validity of the German Shoulder Pain and Disability Index (SPADI). Rheumatol Oxf Engl 2007; 46: 87-92
• 23 John M, Angst F, Awiszus F. et al. The American Shoulder and Elbow Surgeons Elbow Questionnaire: cross-cultural adaptation into German and evaluation of its psychometric properties. J Hand Ther Off J Am Soc Hand Ther 2010; 23: 301-313
• 24 Boehm D, Wollmerstedt N, Doesch M. et al. Development of a questionnaire based on the Constant-Murley-Score for self-evaluation of shoulder function by patients. Unfallchirurg 2004; 107: 397-402
• 25 Huber W, Hofstaetter JG, Hanslik-Schnabel B. et al. The German version of the Oxford Shoulder Score – cross-cultural adaptation and validation. Arch Orthop Trauma Surg 2004; 124: 531-536
• 26 Ortega-Castillo M, Cuesta-Vargas A, Melloh M. et al. Cross-Cultural Adaptation and Validation of the German Version of the Upper Limb Functional Index. J Sport Rehabil 2024; 33: 630-638
• 27 Huber W, Hofstaetter JG, Hanslik-Schnabel B. et al. [Translation and psychometric testing of the Western Ontario Rotator Cuff Index (WORC) for use in Germany]. Z Orthop Ihre Grenzgeb 2005; 143: 453-460
• 28 Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med 2001; 16: 606-613
• 29 Bullinger M. German translation and psychometric testing of the SF-36 Health Survey: preliminary results from the IQOLA Project. International Quality of Life Assessment. Soc Sci Med 1982 1995; 41: 1359-1366
• 30 Huber W, Hofstaetter JG, Hanslik-Schnabel B. et al. [Translation and psychometric testing of the Rotator Cuff Quality-of-Life Measure (RC-QOL) for use in German-speaking regions]. Z Rheumatol 2005; 64: 188-197
• 31 Bartlett O, Farnsworth JL. The Influence of Kinesiophobia on Perceived Disability in Patients with an Upper-Extremity Injury: A Critically Appraised Topic. J Sport Rehabil 2021; 30: 818-823
• 32 Pagels L, Lüdtke K, Schäfer A. Validation of the German version of the Fear-Avoidance Beliefs Questionnaire (FABQ-D) for shoulder disorders. Schmerz Berl Ger 2023; 37: 350-359
• 33 Pagels L, Lüdtke K, Schäfer A. Kinesiophobia in shoulder disorders: Validation of the German version of the Tampa scale for kinesiophobia (TSK-GV). Schmerz Berl Ger 2024; 38: 198-204
• 34 Meyer K, Sprott H, Mannion AF. Cross-cultural adaptation, reliability, and validity of the German version of the Pain Catastrophizing Scale. J Psychosom Res 2008; 64: 469-478
• 35 Toney CM, Games KE, Winkelmann ZK. et al. Using Tuning-Fork Tests in Diagnosing Fractures. J Athl Train 2016; 51: 498-499
• 36 Gismervik SØ, Drogset JO, Granviken F. et al. Physical examination tests of the shoulder: a systematic review and meta-analysis of diagnostic test performance. BMC Musculoskelet Disord 2017; 18: 41
• 37 Willmore EG, Smith MJ. Scapular dyskinesia: evolution towards a systems-based approach. Shoulder Elb 2016; 8: 61-70
• 38 Balevi Batur E, Bekin Sarıkaya PZ, Kaygısız ME. et al. Diagnostic Dilemma: Which Clinical Tests Are Most Accurate for Diagnosing Supraspinatus Muscle Tears and Tendinosis When Compared to Magnetic Resonance Imaging?. Cureus 2022; 14: e25903
• 39 Michener LA, Walsworth MK, Doukas WC. et al. Reliability and Diagnostic Accuracy of 5 Physical Examination Tests and Combination of Tests for Subacromial Impingement. Arch Phys Med Rehabil 2009; 90: 1898-1903
• 40 Requejo-Salinas N, Lewis J, Michener LA. et al. International physical therapists consensus on clinical descriptors for diagnosing rotator cuff related shoulder pain: A Delphi study. Braz J Phys Ther 2022; 26: 100395
• 41 Jain NB, Luz J, Higgins LD. et al. The Diagnostic Accuracy of Special Tests for Rotator Cuff Tear: The ROW Cohort Study. Am J Phys Med Rehabil 2017; 96: 176-183
• 42 Lewis J. Rotator cuff related shoulder pain: Assessment, management and uncertainties. Man Ther 2016; 23: 57-68
• 43 Pieters L, Lewis J, Kuppens K. et al. An Update of Systematic Reviews Examining the Effectiveness of Conservative Physical Therapy Interventions for Subacromial Shoulder Pain. J Orthop Sports Phys Ther 2020; 50: 131-141
• 44 Green S, Buchbinder R, Hetrick SE. Physiotherapy interventions for shoulder pain. Cochrane Database Syst Rev 2003;
• 45 Kuhn JE. Exercise in the treatment of rotator cuff impingement: A systematic review and a synthesized evidence-based rehabilitation protocol. J Shoulder Elbow Surg 2009; 18: 138-160
• 46 Tauqeer S, Arooj A, Shakeel H. Effects of manual therapy in addition to stretching and strengthening exercises to improve scapular range of motion, functional capacity and pain in patients with shoulder impingement syndrome: a randomized controlled trial. BMC Musculoskelet Disord 2024; 25: 192
• 47 Aguilar GarcíaM, González MuñozA, Pérez MontillaJJ. et al. Which Multimodal Physiotherapy Treatment Is the Most Effective in People with Shoulder Pain? A Systematic Review and Meta-Analyses. Healthc Basel Switz 2024; 12: 1234
• 48 Paraskevopoulos E, Plakoutsis G, Chronopoulos E. et al. Effectiveness of Combined Program of Manual Therapy and Exercise Vs Exercise Only in Patients with Rotator Cuff-related Shoulder Pain: A Systematic Review and Meta-analysis. Sports Health 2023; 15: 727-735
• 49 Barrett E, O’Keeffe M, O’Sullivan K. et al. Is thoracic spine posture associated with shoulder pain, range of motion and function? A systematic review. Man Ther 2016; 26: 38-46
• 50 Slater D, Korakakis V, O’Sullivan P. et al. „Sit Up Straight“: Time to Re-evaluate. J Orthop Sports Phys Ther 2019; 49: 562-564
• 51 Kelly SM, Wrightson PA, Meads CA. Clinical outcomes of exercise in the management of subacromial impingement syndrome: a systematic review. Clin Rehabil 2010; 24: 99-109
• 52 Kromer TO, Tautenhahn UG, Bie RA de. et al. Effects of physiotherapy in patients with shoulder impingement syndrome: a systematic review of the literature. J Rehabil Med 2009; 41: 870-880
• 53 Francisco IM, Tozzo MC, Martins J. et al. Adherence of individuals with shoulder pain to home exercise booklets: Barriers, facilitators, and the impact of disability, self-efficacy, and treatment expectations. Musculoskelet Sci Pract 2024; 72
• 54 Santello G, Martins J, Rossi DM. et al. Facilitators and barriers for adherence of shoulder pain patients to a home-based exercise program: cross-sectional study. BrJP 2023; 6: 68-74
• 55 Martinez-Calderon J, Struyf F, Meeus M. et al. Influence of psychological factors on the prognosis of chronic shoulder pain: protocol for a prospective cohort study. BMJ Open 2017; 7: e012822
• 56 Martinez-Calderon J, Meeus M, Struyf F. et al. The role of psychological factors in the perpetuation of pain intensity and disability in people with chronic shoulder pain: a systematic review. BMJ Open 2018; 8: e020703