In most shoulder pain, surgery would only have a placebo effect according to the most recent studies. This is underlined by a panel of experts who recommend reducing the indications.
Surgery should not be performed in the majority of patients with impingement shoulder pain, otherwise known as ‘simple painful shoulder’ or ‘subacromial impingement’ (rotator cuff disease). This is confirmed by a panel of international experts in the BMJ.
This recommendation against surgery is based on a body of new studies showing that this acromioplasty surgery does not improve pain, mobility or quality of life enough, compared to other treatment options.
A change in practices
According to these experts, this new recommendation, based on solid facts, should change practices, given the risk of complications for patients and waste of health care resources for society.
These recommendations are part of the “BMJ Rapid Recommendations” initiative, which aims to produce rapid and reliable recommendations based on the most recent and most conclusive studies. All this to help doctors make better decisions with their patients.
Subacromial impingement
Subacromial impingement shoulder pain refers to non-traumatic shoulder pain associated with weakness or limitation of movement, particularly during arm elevation-abduction.
This type of pain is common in people over the age of 40 and decompression surgery (“acromioplasty”) is a frequently proposed surgery if pain and other problems do not go away after standard medical treatment (painkillers, NSAIDs or infiltration + rehabilitation in decaptation of the shoulder). In 2010, 21,000 such procedures were carried out in NHS hospitals (public hospitals in the UK), at a cost of around £50 million.
However, several recent trials have shown that decompression surgery has no benefit over placebo, or other treatments such as painkillers, rehabilitation and corticosteroid injections, combined with rehabilitation.
Multidisciplinary recommendations
The international panel brought together by the BMJ was made up of orthopedic surgeons, physiotherapists, clinical physicians experienced in the treatment of shoulder pain, as well as patients suffering from this condition. They conducted a detailed analysis of the latest available data and developed recommendations in accordance with the standards governing good development practice, integrating the GRADE approach (system used to assess the quality of evidence).
This strong recommendation against surgery is based on two systematic reviews of the evidence, one based on the benefits and harms of decompression surgery and the other on the significant improvements in pain, upper extremity mobility and patient quality of life.
Too much surgery and too much expense
The expert panel is therefore convinced that acromioplasty-type surgery does not provide any significant benefit in terms of pain, function, quality of life or perceived improvement in the majority of these patients. The surgery is also expensive and potentially dangerous.
“Physicians should not offer patients subacromial decompression surgery without specific justification,” according to the experts on the panel. However, the same experts point out that there is great variability in alternative care and that it deserves to be better defined.
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