Shoulder and back pain in lifters

Three of the most common recommendations for shoulder pain — surgery, more volume, heavier load — have each been tested against a fair comparator and failed.

What the evidence shows

Findings are grouped by what kind of evidence each one is. That ordering is the point: a sentence from an FDA label and a sentence from a forum are not the same claim, and this page will not present them as though they were.

Clinical trial evidence

• Arthroscopic subacromial decompression was no better than placebo (arthroscopy-only) surgery for shoulder pain and function at 6 months; both surgical arms beat no treatment by an amount the investigators judged not clinically important. [1]

  Studied in: 313 UK adults with subacromial pain for at least 3 months, intact rotator cuff tendons, who had ALREADY completed a non-operative programme including exercise therapy and at least one steroid injection - i.e. the failed-conservative-care group, not a first-presentation lifter

• In a double-blind sham-surgery trial, subacromial decompression gave no benefit over diagnostic arthroscopy at 24 months. The trial's own authors warn that the apparent edge of surgery over exercise therapy in that trial is biased in surgery's favour. [2]

  Studied in: 210 patients in three Finnish public hospitals with symptoms consistent with shoulder impingement syndrome, two-year follow-up

• At 5 years, subacromial decompression was no better than placebo surgery AND no better than exercise therapy - the small 2-year difference favouring surgery over exercise had disappeared. This is the cleanest answer to 'surgery or rehab?': at five years there is nothing in it. [3]

  Studied in: 210 patients aged 35-65 years with shoulder impingement symptoms for more than 3 months; 175 (83%) completed 5-year follow-up

• Cochrane rates the no-benefit finding for subacromial decompression as high-certainty evidence, and puts the risk of a serious surgical complication at roughly 5-7 per 1000 within 30 days - small, but not zero, and it buys nothing. [4]

  Studied in: 8 trials, 1062 randomised participants with rotator cuff disease (full-thickness tears EXCLUDED), participant mean age 42 to 65 years

• A specific eccentric rotator-cuff plus scapular-stabiliser programme, done at home once or twice daily for 12 weeks with 5-6 supervised sessions, cut the proportion of patients who went on to choose surgery from 63% to 20%. This is the single most concrete exercise prescription in the shoulder literature with a hard behavioural endpoint. [5]

  Dose or parameter studied: Eccentric strengthening for the rotator cuff plus concentric/eccentric scapular-stabiliser exercise with manual mobilisation; home exercise once or twice a day for 12 weeks, plus 5-6 individually guided supervised sessions across the same 12 weeks

  Studied in: 102 patients with persistent subacromial impingement syndrome of more than six months in whom earlier conservative treatment had already failed, recruited through orthopaedic specialists at a Swedish university hospital

• There is no consensus sets-and-reps prescription for rotator cuff-related shoulder pain. Across 46 exercise programmes in 22 randomised trials, frequency ranged 2-7 times per week, volume 1-3 sets of 4-30 reps, and duration 4-16 weeks. Any single number an app prints is one trial's arbitrary choice. [6]

  Dose or parameter studied: Across trials: 2 to 7 sessions per week; 1 to 3 sets; 4 to 30 repetitions per set; programme duration 4 to 16 weeks

  Studied in: 46 exercise programmes extracted from 22 RCTs in people with rotator cuff-related shoulder pain (motor control, scapula-focused, eccentric and nonspecific programme types)

• Doubling the total dose of shoulder strengthening on top of usual care produced no additional benefit. Roughly half of all patients still had unacceptable symptoms at 4 months regardless of group - more volume is not the missing ingredient. [7]

  Dose or parameter studied: Add-on progressive home resistance training with an elastic band, designed to at least double the total dose of shoulder strengthening versus usual care alone; primary endpoint at 4 months, minimal clinically important difference set at 10 SPADI points

  Studied in: 200 consecutive patients aged 18-65 referred to orthopaedic shoulder specialist care with subacromial impingement and shoulder pain lasting more than 3 months

• Progressive HIGH-load exercise was not superior to traditional low-load exercise for rotator cuff tendinopathy over 12 weeks. Loading heavy is not required to get the benefit - relevant to lifters who assume the fix must look like their training. [8]

  Dose or parameter studied: 12 weeks of progressive high-load exercise versus low-load exercise; primary endpoint change in DASH at 12 weeks

  Studied in: 100 patients with rotator cuff tendinopathy in Danish shoulder clinics, randomised to progressive high-load (n=49) or low-load (n=51), stratified for concomitant corticosteroid injection

• A supervised progressive exercise programme of up to 6 sessions was no better over 12 months than a single best-practice advice session, and adding a subacromial corticosteroid injection gave no long-term benefit either. [9]

  Dose or parameter studied: Progressive exercise programme of 6 or fewer physiotherapy sessions versus one best-practice advice session, each with or without a single subacromial corticosteroid injection; outcomes analysed over 12 months

  Studied in: 708 UK adults aged 18+ with a rotator cuff disorder, new episode within the past 6 months; excluded significant trauma, full-thickness tears requiring surgery, frozen shoulder, inflammatory arthritis, or any injection/physiotherapy for shoulder pain in the past 6 months

• Exercising into pain is not harmful and gives a small short-term pain advantage over strictly pain-free exercise; by medium and long term the two are equivalent. Pain during rehab loading is not by itself a stop signal. [10]

  Studied in: 9 papers from 7 randomised trials, 385 participants with chronic musculoskeletal pain (mixed sites, not lifters specifically)

• Serious spinal pathology in people presenting with acute low back pain is rare (0.9%), yet 80% of them have at least one textbook 'red flag'. Only three fracture red flags carried real information: prolonged corticosteroid use, age over 70, and significant trauma. A red flag on its own is close to meaningless. [11]

  Studied in: Inception cohort of 1,172 consecutive patients receiving primary care for acute low back pain in Sydney, Australia, with 12-month follow-up as reference standard

• The red flags that actually move the probability of fracture are prolonged corticosteroid use (33% post-test probability), a visible contusion or abrasion (62%), severe trauma (11%) and older age (9%); multiple flags together reach 90%. For malignancy, only a prior history of cancer counts (33%). Most other listed red flags change nothing. [12]

  Studied in: 14 studies (8 primary care, 2 secondary care, 4 tertiary care) of patients presenting with low back pain; only 5 studies evaluated combinations of red flags

• In emergency-department low back pain series, spinal cord or cauda equina compression accounted for 0.1-1.9% of presentations and infection for up to 1.9%. Injection drug use, indwelling vascular catheters and other infection sites are among the features that raise the likelihood of epidural abscess - directly relevant to anyone self-injecting. [13]

  Studied in: 22 studies, 41,320 patients presenting with low back pain to emergency departments (a higher-acuity population than primary care)

• For acute low back pain, advice to stay active beats advice to rest in bed, though the effect is small. For sciatica specifically, there is moderate-quality evidence of little or no difference between the two. Bed rest is not a treatment. [14]

  Studied in: 10 RCTs of varying risk of bias; acute low back pain analysis N=401 across two trials, plus separate sciatica trials

• Exercise for chronic low back pain produces a clinically important pain reduction versus no treatment, usual care or placebo (15 points on a 0-100 scale), but only a small effect on function. Adverse events were reported in about a third of exercise groups and a similar third of comparison groups, and were mostly muscle soreness. [15]

  Studied in: 249 trials of adults with chronic non-specific low back pain of more than 12 weeks' duration; mean age 43.7 years, 59% female on average

• Posterior-chain resistance training (thoracic, lumbar and hip extensors) beat general exercise for pain, disability and strength in chronic low back pain, with the benefit concentrated in programmes lasting 12-16 weeks rather than 6-8. Adverse event rates did not differ - loading the back was not more dangerous than general exercise. [16]

  Dose or parameter studied: Posterior-chain resistance training focused on thoracic, lumbar and hip extensor musculature, programmes of at least 6 weeks; the significant advantage over general exercise appeared at 12-16 weeks

  Studied in: 8 RCTs, 408 participants (203 posterior-chain resistance training, 205 general exercise) described as recreationally active and sedentary individuals with chronic low back pain - NOT trained lifters

• A deadlift-based high-load lifting programme and a low-load motor control programme both improved pain, strength and endurance in recurrent low back pain over 12 sessions in 8 weeks. Neither beat the other on pain intensity; the low-load arm was better on self-selected activity and movement control. Heavy lifting is a viable rehab route, not a superior one. [17]

  Dose or parameter studied: 12 treatment sessions over an 8-week period, plus pain-mechanism education in both arms; high-load lifting (deadlift-based) versus individualised low-load motor control exercise

  Studied in: 70 participants with recurrent low back pain diagnosed with nociceptive mechanical pain as their dominating pain pattern - a subgroup selected for mechanically provoked pain, closest of any trial here to a lifter presentation

• Cognitive functional therapy - graded re-exposure to feared movement plus targeting unhelpful beliefs - delivered in up to seven sessions over 12 weeks plus one booster produced large, sustained reductions in activity limitation versus usual care, holding at 52 weeks. Adding movement-sensor biofeedback added nothing. [18]

  Dose or parameter studied: Up to seven treatment sessions over 12 weeks plus a booster session at 26 weeks; primary endpoint Roland Morris Disability Questionnaire at 13 weeks

  Studied in: 492 Australian primary-care adults with low back pain lasting more than 3 months and at least moderate pain-related physical activity limitation; serious spinal pathology was an exclusion criterion

• Ibuprofen at 1200 mg/day for 8 weeks measurably blunted muscle growth and strength gains from resistance training compared with low-dose aspirin. Using maximal over-the-counter NSAID doses to train through shoulder or back pain has a real cost to adaptation. [20]

  Dose or parameter studied: Ibuprofen 1200 mg/day (maximal over-the-counter dose) versus acetylsalicylic acid 75 mg/day, both daily for 8 weeks, alongside supervised knee-extensor resistance training

  Studied in: 31 healthy men and women aged 18-35 years; knee-extensor training model, not a shoulder or back pain population

Off-label use of an approved drug

• Long-term AAS users who lift had stiffer patellar tendons and 15% higher maximal tendon stress than trained non-users, which the authors flag as a possible route to higher tendon injury risk. This is a mechanistic signal in humans, not an injury-rate finding. [21]

  Studied in: Men with a history of long-term resistance training and AAS use, compared with resistance-trained non-users and untrained controls; in vivo ultrasonography and dynamometry of the patellar tendon. Cross-sectional - it cannot establish that AAS caused the difference or that injuries followed

Observational or community-reported

• Among subelite powerlifters, 70% were currently injured and 87% had been injured in the past year, with the lumbopelvic region and shoulder the two commonest sites - yet only 16% of the currently injured had to stop training entirely. Pain in these two areas is close to baseline in this population, and most people work around it rather than stopping. [19]

  Studied in: 104 Swedish subelite classic powerlifters (53 women, 51 men) answering an online questionnaire - self-report, cross-sectional, cannot show whether continuing to train helps or harms

Animal or mechanistic only

• BPC-157, widely used for shoulder and back injuries in lifting communities, has essentially no human evidence. A 2025 review found only three human pilot studies in ANY indication - none of them a tendon or musculoskeletal efficacy trial. It should be treated as investigational. [22]

  Studied in: Animal models across numerous preclinical studies, plus three human pilot studies. No trial in rotator cuff or lumbar injury, and no trial in resistance-trained adults

What the regulator approved

Where a drug on this page has a US label, this is what it was approved for and at what dose. Anything else is off-label — which is not the same as unsafe, but does mean no regulator has reviewed it for that use.

What nobody knows

These are the questions the literature does not answer. They are listed because on this subject the gaps are load-bearing: most of what circulates as settled practice sits in one of them.

• POPULATION MISMATCH IS THE BIGGEST GAP. Not one trial retrieved here enrolled resistance-trained lifters. Cochrane's chronic low back pain population had a mean age of 43.7 years and was 59% female; FIMPACT enrolled ages 35-65; CSAW required patients to have already failed exercise plus a steroid injection; the posterior-chain meta-analysis explicitly described 'recreationally active and sedentary' participants. Everything below about sets, reps and surgery-versus-exercise is being extrapolated to someone squatting or benching near their 1RM. That extrapolation is assumed, never tested.
• NO TRIAL HAS TESTED DELOAD VERSUS FULL REST VERSUS TRAINING THROUGH IT IN LIFTERS. Stromback shows 70% of subelite powerlifters are currently injured and only 16% of those stop training entirely - but that is a cross-sectional questionnaire and cannot say whether continuing helped or harmed them. The 'graded reloading beats rest' evidence is from advice-to-stay-active trials in acute low back pain and general-population exercise trials, not from a trial that manipulated barbell load after an injury.
• THERE IS NO VALIDATED SETS/REPS PRESCRIPTION FOR SHOULDER PAIN. The JOSPT scoping review of 46 programmes found 2-7 sessions/week, 1-3 sets, 4-30 reps, 4-16 weeks, and concluded there was 'no one-size-fits-all approach'. Any specific number this app prints is one trial's arbitrary choice presented as a dose. Holmgren's once-or-twice-daily-for-12-weeks is the best-evidenced single protocol only because it has a hard endpoint (surgery avoided), not because that dose was compared against alternatives.
• MORE AND HEAVIER BOTH FAILED. Doubling strengthening volume (SExSI) and using progressive high load instead of low load (RoCTEx) each failed to beat their comparator, and about half of SExSI patients still had unacceptable symptoms at 4 months. So the mechanism by which shoulder exercise works, and who responds, is not established - which means there is no rational basis for tuning the dose upward when someone is not improving.
• RED FLAG ACCURACY HAS NOT BEEN STUDIED IN YOUNG ATHLETIC POPULATIONS. The Henschke (0.9% serious pathology) and Downie post-test probabilities come from primary care, and Galliker from emergency departments. In a healthy 30-year-old lifter the base rate is lower still, and two flags behave oddly: 'severe trauma' will fire on any failed heavy lift (raising false positives), while 'prolonged corticosteroid use' - the single strongest fracture flag at 33% post-test probability - is directly applicable to anyone who has run oral or injected glucocorticoids and is routinely not asked about.
• SELF-TRIAGE RULES ARE UNVALIDATED. Every red flag dataset here describes CLINICIAN-administered questions with a clinical reference standard. No study has validated a lay-user or app-delivered version. Cauda equina and cord compression (0.1-1.9% of ED low back pain presentations) is the clearest reason to have an absolute stop rule, but the accuracy of any self-administered version of that rule is unknown.
• INFECTION RISK IN AN INJECTING POPULATION IS UNQUANTIFIED FOR THIS GROUP. Galliker lists intravenous drug use, indwelling vascular catheters and other infection sites as features raising the likelihood of epidural abscess. Nobody has measured spinal or soft-tissue infection rates in people self-injecting hormones or peptides, so the size of this risk for this app's readers is unknown - only its direction is.
• AAS AND TENDON: MECHANISM ONLY, NO OUTCOMES. Seynnes found 26% higher patellar tendon stiffness and 15% higher maximal tendon stress in long-term AAS users versus trained non-users and raised injury risk as a hypothesis. There is no prospective injury-rate study, no compound or dose was quantified, and no study has asked whether AAS or TRT use changes how someone responds to shoulder or back rehabilitation.
• PEPTIDES HAVE NO EVIDENCE BASE HERE AT ALL. A PubMed search for BPC-157 human tendon-healing trials returned zero results; the 2025 review found only three human pilot studies in any indication and no musculoskeletal efficacy trial. Community BPC-157 and TB-500 dosing protocols have no clinical source, no safety trial, and no verification of purity or identity from unregulated supply. Anything this app says about a peptide dose for a rotator cuff or a disc is unsourced by construction.
• NSAID DOSE-RESPONSE FOR ADAPTATION IS UNKNOWN. Lilja showed 1200 mg/day ibuprofen for 8 weeks blunts hypertrophy and strength - but in a knee-extensor model, in young adults, at the maximum OTC dose taken daily. Whether an occasional 400 mg dose, a 5-day course for acute bursitis, or naproxen at labelled doses meaningfully affects training adaptation or tendon healing has not been tested. Do not present the Lilja result as a blanket 'NSAIDs block gains'.
• NO POST-INJECTION LOADING PROTOCOL EXISTS. GRASP found subacromial corticosteroid injection gave no long-term benefit, but no trial reports what happens to people who return to heavy overhead or pressing work soon after an injection. There is no trial-derived guidance on when to reload after a steroid shot, and the methylprednisolone label text retrieved did not contain a subacromial-specific dose or any return-to-activity instruction.
• FULL-THICKNESS TEARS ARE OUTSIDE ALL OF THIS. CSAW required intact rotator cuff tendons and the Cochrane review excluded full-thickness tears. None of the surgery-versus-exercise conclusions above apply to someone with a full-thickness tear, and this app has no way to distinguish that from tendinopathy without imaging - which Chou's meta-analysis says should not be ordered routinely in the absence of red flags anyway.
• DURABILITY BEYOND A YEAR IS THIN FOR LOW BACK EXERCISE. Cochrane's clinically important pain effect (MD -15.2) was at 'earliest follow-up'; effects against other conservative treatments were smaller and not clinically important. Long-term maintenance - the actual question for someone who intends to lift for decades - is not well characterised.

Sources

Every identifier below was checked to resolve to a real record before publication. Citations retrieved from PubMed and DailyMed.

1. Lancet (2018) — PubMed 29169668 Mean Oxford Shoulder Score did not differ between the two surgical groups at 6 months (decompression mean 32·7 points [SD 11·6] vs arthroscopy mean 34·2 points [9·2]; mean difference -1·3 points (95% CI -3·9 to 1·3, p=0·3141). Both surgical groups showed a sma
2. BMJ (2018) — PubMed 30026230 In this controlled trial involving patients with a shoulder impingement syndrome, arthroscopic subacromial decompression provided no benefit over diagnostic arthroscopy at 24 months. ... Of note, this ASD versus exercise therapy comparison is not only confound
3. British Journal of Sports Medicine (2021) — PubMed 33020137 In our secondary comparison (ASD vs exercise therapy), the mean differences between groups (ASD minus exercise therapy) in pain VAS were 1.0 (-5.6 to 7.6; p=0.77) at rest and -3.9 (-12.8 to 5.1; p=0.40) on arm activity. There were no significant between-group
4. Cochrane Database of Systematic Reviews (2019) — PubMed 30707445 Compared with placebo, high-certainty evidence indicates that subacromial decompression provides no improvement in pain, shoulder function, or health-related quality of life up to one year, and probably no improvement in global success (moderate-certainty evid
5. BMJ (2012) — PubMed 22349588 The specific exercise strategy consisted of strengthening eccentric exercises for the rotator cuff and concentric/eccentric exercises for the scapula stabilisers in combination with manual mobilisation. The control exercise programme consisted of unspecific mo
6. Journal of Orthopaedic & Sports Physical Therapy (2024) — PubMed 38832666 The different program types had similar parameters. Exercise programs frequency ranged from 2 to 7 times per week, dose ranged from 1 to 3 sets and 4 to 30 repetitions per sets, and exercise program duration ranged from 4 to 16 weeks. There was considerable va
7. American Journal of Sports Medicine (2021) — PubMed 34048281 From baseline to 4-month follow-up, SPADI scores improved in both groups (intention-to-treat analysis; IG, -22.1 points; CG, -22.7 points; between-group mean difference, 0.6 points [95% CI, -5.5 to 6.6]). At 4 months after randomization, only 54% of the IG and
8. Orthopaedic Journal of Sports Medicine (2017) — PubMed 28875153 Mean changes in the DASH questionnaire were 7.11 points (95% CI, 3.07-11.16) and 8.39 points (95% CI, 4.35-12.44) in the PHLE and LLE groups, respectively; this corresponded to a statistically nonsignificant adjusted mean group difference of -1.37 points (95%
9. Lancet (2021) — PubMed 34265255 We found no evidence of a difference in SPADI score between progressive exercise and best practice advice when analysed over 12 months (adjusted mean difference -0·66 [99% CI -4·52 to 3·20]). We also found no evidence of a difference between corticosteroid inj
10. British Journal of Sports Medicine (2017) — PubMed 28596288 There was short- term significant difference in pain, with moderate quality evidence for a small effect size of -0.27 (-0.54 to -0.05) in favour of painful exercises. For pain in the medium and long term, and function and disability in the short, medium and lo
11. Arthritis & Rheumatism (2009) — PubMed 19790051 There were 11 cases (0.9%) of serious pathology, including 8 cases of fracture. Despite the low prevalence of serious pathology, most patients (80.4%) had at least 1 red flag (median 2, interquartile range 1-3). Only 3 of the red flags for fracture recommended
12. BMJ (2013) — PubMed 24335669 The red flags with the highest post-test probability for detection of fracture were older age (9%, 95% confidence interval 3% to 25%), prolonged use of corticosteroid drugs (33%, 10% to 67%), severe trauma (11%, 8% to 16%), and presence of a contusion or abras
13. The American Journal of Medicine (2020) — PubMed 31278933 The prevalence of any requiring immediate/urgent treatment was 2.5%-5.1% in prospective and 0.7%-7.4% in retrospective studies (0.0%-7.2% for vertebral fractures, 0.0%-2.1% for spinal cancer, 0.0%-1.9% for infectious disorders, 0.1%-1.9% for pathologies with s
14. Cochrane Database of Systematic Reviews (2010) — PubMed 20556780 For patients with acute LBP, results from two trials (N = 401) suggest small improvements in pain relief (SMD 0.22 (95% CI: 0.02 to 0.41) and functional status (SMD 0.29 (95% CI: 0.09 to 0.49) in favour of advice to stay active. For patients with sciatica, the
15. Cochrane Database of Systematic Reviews (2021) — PubMed 34580864 We found moderate-certainty evidence that exercise treatment is more effective for treatment of chronic low back pain compared to no treatment, usual care or placebo comparisons for pain outcomes at earliest follow-up (MD -15.2, 95% CI -18.3 to -12.2), a clini
16. Sports Medicine - Open (2021) — PubMed 33683497 Specifically, when compared to GE, PCRT demonstrated a greater reduction in pain (SMD = - 0.61 (95% CI - 1.21 to 0.00), p = 0.05; I = 74%) and level of disability (SMD = - 0.53 (95% CI - 0.97 to - 0.09), p = 0.02; I = 52%), as well as a greater increase in mus
17. Journal of Orthopaedic & Sports Physical Therapy (2015) — PubMed 25641309 Seventy participants with recurrent low back pain, who were diagnosed with nociceptive mechanical pain as their dominating pain pattern, were randomized to either LMC or HLL exercise treatments. Participants were offered 12 treatment sessions over an 8-week pe
18. Lancet (2023) — PubMed 37146623 Participants in both interventions received up to seven treatment sessions over 12 weeks plus a booster session at 26 weeks. ... Both interventions were more effective than usual care (CFT only mean difference -4·6 [95% CI -5·9 to -3·4] and CFT plus biofeedbac
19. Orthopaedic Journal of Sports Medicine (2018) — PubMed 29785405 Seventy percent (73/104) of participants were currently injured, and 87% (83/95) had experienced an injury within the past 12 months. The lumbopelvic region, shoulder, and hip were the most commonly injured areas for both sexes. ... Injuries seemed to occur du
20. Acta Physiologica (2018) — PubMed 28834248 Healthy men and women (aged 18-35 years) were randomly assigned to daily consumption of ibuprofen (IBU; 1200 mg; n = 15) or acetylsalicylic acid (ASA; 75 mg; n = 16) for 8 weeks. ... The increase in m. quadriceps volume was similar between FW and WS, yet was (
21. Journal of Applied Physiology (2013) — PubMed 23620489 However, stiffness and modulus were higher in the RTS group (26%, P < 0.05 and 30%, P < 0.01, respectively) than in the RT group. ... Yet maximal tendon stress was higher in RTS than in RT (15%, P < 0.05), without any statistical difference in maximal strain a
22. Current Reviews in Musculoskeletal Medicine (2025) — PubMed 40789979 Despite broad preclinical support, human data are extremely limited. Only three pilot studies have examined BPC-157 in humans, including its use for intraarticular knee pain, interstitial cystitis, and intravenous safety/pharmacokinetics. No adverse effects we
23. Naproxen sodium (oral tablets) — US Prescribing Information (DailyMed) Approved indication: The FDA label lists relief of the signs and symptoms of tendonitis, bursitis and acute gout, plus rheumatoid arthritis, osteoarthritis, ankylosing spondylitis and polyarticular juvenile idiopathic art
24. Ibuprofen (OTC capsules) — US Prescribing Information (DailyMed) Approved indication: Retrieved OTC label Uses section: 'temporarily relieves minor aches and pains due to: headache muscular aches minor pain of arthritis toothache backache the common cold muscular cramps' and 'temporari
25. Methylprednisolone acetate injectable suspension (subacromial corticosteroid injection) — US Prescribing Information (DailyMed) Approved indication: IMPORTANT RETRIEVAL LIMIT: the Indications and Usage text returned by the label lookup covered intramuscular use for allergic states, dermatologic diseases, endocrine disorders and gastrointestinal di

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