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Surgery = no surgery for patients with subacromial shoulder pain (CSAW)
Clinical Question
Do patients with subacromial shoulder pain for at least 3 months who are treated surgically have better outcomes than those who are treated without surgery?
Bottom line
In patients with subacromial shoulder pain of at least 3 months duration who receive physical therapy, surgical decompression is no better than arthroscopy without decompression in improving pain or function… and neither is much better than no invasive intervention at all. 1b
Reference
Study design: Randomized controlled trial (double-blinded)
Funding: Government
Setting: Outpatient (specialty)
Synopsis
These authors randomized adults with subacromial pain of at least 3 months duration into 1 of 3 groups: arthroscopic decompression of the acromion (n = 106), arthroscopy without decompression (n = 103), or no additional treatment (n = 104). Before enrollment, all patients underwent physical therapy and had at least one corticosteroid injection. The authors excluded patients with complete rotator cuff tears. A healthy percentage of the patients (23%, 42%, and 12%, respectively) allocated to decompression, arthroscopy only, and no treatment did not receive their assigned treatment by 6 months because they were already better! Additionally, approximately 15% of the patients did not complete 12 months of follow up. After 6 months and 1 year, the patients treated with either surgical decompression or arthroscopy without decompression had improvements in pain and function (as measured by the Oxford Shoulder Score) compared with patients who received no treatment, but the differences were not clinically important. Additionally, there was no difference between the decompression and arthroscopy without decompression groups. Two patients in each group developed adhesive capsulitis. The authors don't report on surgical complications.
Reviewer
Henry C. Barry, MD, MS
Professor
Michigan State University
East Lansing, MI
Comments
Pour ces patients je vais les encourager à faire des programmes de physiothérapie plus poussés pour tenter d’éviter de les envoyer en orthopédie.
so ... arthroscopic decompression of the shoulder for chronic pain = placebo
Experience, (not science)
I personally had what was diagnosed as impingement syndrome, (met the various tests), with pain for well beyond the 3 month horizon in this study. 3 months' worth of weekly physiotherapy, ( a scatter gun mix of interferential Rx, heat, mobilisation, directed at both shoulder and neck, plus acupuncture, only resulted in exacerbation of the pain. When I stopped the physio the pain gradually subsided completely. My belief, (and, based on a single potentially biased subject, it cannot be anything more scientific), is that this is an inherently self-limited condition, (at least in some cases), and attempts to "treat" it are not only self-deceiving, but potentially harmful.
"improvements in pain and function (as measured by the Oxford Shoulder Score) compared with patients who received no treatment, but the differences were not clinically important", but I would think if it was your shoulder that had less pain, you would find that important.
less surgery is better ! see also DBRTrial on knee arthroscopy : the magic of MIS arthroscopy is over !
Shoulder pain with and without surgery.
A brave paper. I wish there were more studies which report so called “negative” results. They are as important to clinicians and patients as studies reporting positive outcomes, yet they make up a minuscule fraction of medical literature
I have already shown that prolotherapy injections, which are much less invasive than surgery as their only side effect is bruising, are highly effective in relieving the sub-acromial shoulder pain that comes with rotator cuff tendinopathy. Bertrand H, Reeves KD, Bennett CJ, Bicknell S, Cheng A-L, Dextrose Prolotherapy versus Control Injections in Painful Rotator Cuff Tendinopathy. Arch Phys Med Rehabil 2016;97: 17-25.
in my experience impingement syndromes of the shoulder are often difficult to manage and no one specialty (physio ortho sportsmed) has a complete insight or uniformly effective approach.
I am amazed how these patients were specialist consulted & arthroscoped by 3 months. Our patients wait 6-12 months just to be seen, with long OR wait times
Good poem
I am not an orthopaedic surgeon but it does remind us of a few points. Sometimes symptoms improve without an intervention; sometimes patients can learn to accommodate and accept their new condition and sometimes our interventions don’t make much of a difference. Clearly, there can be patients that can benefit from interventions and as physicians and surgeons we need to be doing a better job at discerning who they are. This is true of a surgical procedure as much as it is true of a prescription for medication or recommendation for physiotherapist.
Subacromial shoulder pain is a pretty heterogeneous category. We need more information of specific diagnoses to make sense of this study