Friday, February 8, 2019

No Surgery for Subacromial Pain Syndrome

Subacromial decompression surgery should not be offered to patients with subacromial pain syndrome, according to a new guideline from The BMJ's Rapid Recommendations panel. The guidance — considered a strong recommendation — applies to patients with atraumatic shoulder pain, including rotator cuff disease, lasting longer than 3 months.

The recommendation was based on findings from seven randomized trials among roughly 1000 patients that compared decompression surgery with either sham surgery or exercise alone. Overall, decompression surgery did not provide a meaningful benefit over nonsurgical treatment in terms of pain, function, or quality-of-life. However, surgery was associated with more cases of frozen shoulder (12 more cases per 1000 patients undergoing surgery) and could cause more serious adverse events like major bleeding.

The panel, which included patients, clinicians, and researchers, concluded: "Almost all informed patients would choose to avoid surgery.... However, there is substantial uncertainty in what alternative treatment is best."

My Take:
The full article is available for free online from the New England Journal of Medicine.

Atraumatic shoulder pain can mean an insidious onset or from a chronic injury (more than six months, but often several years old). Much like the recent recommendations on knee surgery, shoulder decompression surgery should be reserved for acute injuries.

In both the knee and shoulder, studies using “sham surgery” show that patients typically recover better when physical therapy is used in place of surgery rather than as an adjunct to surgery. Unfortunately, to remove bias, the subjects need to think they actually had surgery to motivate them to work hard in physical therapy. So “sham surgery” fakes the surgical procedure. The patient actually believes their shoulder or knee underwent surgery.

In a related surgical change, for patients over the age of 45 suffering an acute ACL (anterior cruciate ligament) tear to the knee, surgery is no longer recommended. Patients are advised to live with the injury or undergo physical therapy. I suspect the same recommendations will eventually follow for acute rotator cuff tear in aging patients.

Most of us will tear a portion of the rotator cuff during the course of our lives. Often, that injury is forgotten over time. When they enter my office, the damage is very chronic with a lot of adhesions. Manipulation of the shoulder, scapula (shoulder blade) and/or AC (acromioclavicular) joint will help breakdown those adhesions and reset the joint(s) in their proper position. Many times manipulation will also relieve shoulder impingement, restoring full strength to the rotator cuff muscles. However, physical therapy is an excellent adjunct to manipulation in restoring rotator cuff strength.

Bottom Line:
The trend to a more conservative approach to both shoulder and knee surgery has been a long time coming. Now that it is becoming the standard of medicine, alternative therapies like manipulation and physical therapy need to be recognized as the treatment of choice.

Source: February 7, 2019 New England Journal of Medicine

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