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Decompression surgery no more effective than exercise for shoulder impingement syndrome
Clinical Question
In patients with symptoms of shoulder impingement syndrome is subacromial decompression surgery more effective than sham arthroscopy or exercise therapy to decrease pain and improve function?
Bottom line
Despite being one of the most common orthopedic surgeries performed, subacromial decompression is not significantly better than physical therapy to treat patients with pain and limited function due to shoulder impingement. This study is backed up by a meta-analysis that found the same results (doi:10.3109/09638288.2014.907364). Get out the stretchy bands or hand weights: another meta-analysis (doi:10.1136/bjsports-2016-096515) demonstrated the benefit of shoulder exercises over other physical therapy modalities. 1a
Reference
Study design: Randomized controlled trial (double-blinded)
Funding: Government
Setting: Outpatient (specialty)
Synopsis
These Finnish researchers enrolled 210 adults aged 35 to 65 years with a clinical presentation of shoulder impingement syndrome who, by magnetic resonance imaging, had no evidence of rotator cuff tear and who had not responded to 3 months of conventional treatment. The patients were first randomized to receive surgery or physical therapy using concealed allocation; patients tapped for surgery underwent diagnostic arthroscopy to rule out tears or other pathology and then, in the operating room, were randomized again to receive arthroscopic subacromial decompression or (to keep everyone unaware of treatment assignment) kept in the operating theater but without further intervention for the length of time of a typical decompression. After 2 years, patients in all 3 groups had a large decrease in reported pain, from approximately 75 to between 20 and 30 on a 100-point visual analog scale. Decompression was statistically better than exercise therapy, but the result would not be clinically relevant (a difference of at least 15 points) and was no different than diagnostic arthroscopy. There was also no difference in pain or function scores at earlier time points. The researchers did not attempt to stratify patients by degree of joint narrowing or by the presence of osteoarthritis or other morphology, and targeted therapy aimed at specific changes may have found a difference in treatment outcomes.
Reviewer
Allen F. Shaughnessy, PharmD, MMedEd
Professor of Family Medicine
Tufts University
Boston, MA
Comments
I get referral for cervical radiculopathy but patient has significant limitation of shoulder movement with tenderness I normally refer them to orthopedic surgeon or rhumatologist, Since waiting list is I started referring them to physio and since most of them were not able to pay so I find handout and few YOUtube video link, But I insisted for follow up in 3 months the result was only few with sever degenerative changes had limited improvement and they have been referred to orthopedic surgeon or rheumatologist, I believe home exercises on regular and more frequent basis is more effective and I always teach or give hand out to patient for self management.
Pre-treatment
Would be useful to describe what is the 3 months of conventional treatment all pts got
It's remarkable how many techniques and approaches for so many ailments are turning out to be so useless. Where did the previous studies, if any, go so wrong?.Perhaps CABGs don't work anymore. There's work forever for researchers to recheck everything,and be temporarily experts, but ultimately wrong, cyclically.
Good to know so that we can avoid non-useful surgery
As per above, this information is harmful.
good poem
I’d be interested to know how the conventional therapy differs from the physical therapy described in this pivotal review
Such an interesting study, but in the era of 'transparency' how does one explain the treatment provided? Those entering the study needed to have been warned of the treatment arm possibilities, and this seems anatomically hard to explain to one in pain.
Why is it that so many surgical interventions only get studied regarding outcome decades later?
What this study totally fails to take into account is that the only way most people can get the time off from the jobs and activities aggravating their shoulder pain, and the time to properly rehabilitate the joint is by having surgery. Sad but too true!
why the need for decompression?
It is unclear why patients would have been referred for surgical decompression in the first place, given that all participants had a preliminary MRI which did not show any evidence of rotator cuff tear.
Excellent