Chronic Shoulder Pain? Think Twice Before Opting for Subacromial Decompression Surgery
Introduction to Subacromial decompression surgery
Subacromial decompression surgery, also known as acromioplasty or subacromial decompression, is a surgical procedure commonly performed to treat shoulder pain and impingement syndrome. The surgery involves removing a portion of the acromion bone and soft tissue in the subacromial space, which is the area between the acromion and the rotator cuff tendons. This is done with the aim of increasing the space available for the rotator cuff tendons to move freely and reduce impingement.
The purpose of this blog post is to provide a comprehensive overview of the latest evidence regarding the effectiveness and risks of subacromial decompression surgery for people suffering from shoulder pain lasting more than three months.
Recent systematic reviews and meta-analyses have raised significant concerns about the benefits of this procedure, and it is crucial for healthcare professionals, policymakers and especially patients to be aware of these findings to make informed decisions about treatment options.
What is Subacromial Decompression Surgery?
Subacromial decompression surgery, also known as acromioplasty or subacromial decompression, is a surgical procedure performed to treat shoulder pain and impingement syndrome. It involves removing a portion of the acromion, which is the bony projection at the top of the shoulder blade (scapula). This procedure aims to create more space for the rotator cuff tendons to move freely under the acromion, reducing impingement and alleviating pain.
During the surgery, the orthopedic surgeon makes an incision in the shoulder area and detaches the deltoid muscle to access the acromion. The surgeon trims or shaves off a part of the acromion, as well as any bone spurs or inflamed bursal tissue that may be causing impingement. In some cases, the surgeon may also release or repair the rotator cuff tendons if they are torn or damaged.
Subacromial decompression surgery is commonly recommended for individuals experiencing persistent shoulder pain and limited range of motion due to conditions such as subacromial impingement syndrome, rotator cuff teninopathy, or partial rotator cuff tears. It is typically considered after non-surgical treatments, such as physiotherapy, anti-inflammatory medications, and corticosteroid injections, have failed to provide adequate relief.
Common indications for subacromial decompression surgery include:
1. Subacromial Impingement Syndrome: This condition occurs when the rotator cuff tendons become compressed or impinged between the acromion and the humerus (upper arm bone), leading to pain and inflammation.
2. Rotator Cuff Tendinopathy (or commonly known as Tendinitis): Chronic inflammation or degeneration of the rotator cuff tendons can cause pain and impaired shoulder movement, particularly during overhead activities.
3. Partial Rotator Cuff Tears: Small tears in the rotator cuff tendons may benefit from decompression surgery to alleviate pain and prevent further tearing.
4. Bone Spurs or Bony Outgrowths: Abnormal bone formations on the acromion or other parts of the shoulder joint can impinge on the rotator cuff tendons, causing pain and limiting movement.
It is important to note that subacromial decompression surgery is typically recommended after conservative treatments have been exhausted and when the patient's symptoms significantly impact their daily activities and quality of life.
Evidence on Effectiveness of Subacromial Decompression Surgery
Recent systematic reviews and meta-analyses have shed light on the effectiveness of subacromial decompression surgery for treating chronic shoulder pain. The findings from these comprehensive studies suggest that the surgery offers no significant benefits over placebo or exercise therapy.
A systematic review and meta-analysis published in the British Medical Journal in 2019 analysed data from seven randomised controlled trials involving over 1,000 patients.
The study found no clinically significant differences in pain, function, or quality of life between patients who underwent subacromial decompression surgery and those who received a placebo surgical procedure.
Another systematic review and meta-analysis published in the Journal of Bone and Joint Surgery in 2017 examined data from nine randomised controlled trials with a total of 1,062 participants. The study concluded that subacromial decompression surgery did not provide better outcomes than exercise therapy for patients with subacromial pain syndrome.
Comparison of Subacromial Decompression Surgery with Placebo Surgery
Several high-quality studies have directly compared subacromial decompression surgery with placebo surgery, where patients undergo a simulated procedure without actual decompression. The results consistently show no significant differences in pain relief, shoulder function, or quality of life between the two groups.
One notable study, published in the Lancet in 2018, involved 313 patients with subacromial pain syndrome who were randomly assigned to either subacromial decompression surgery or placebo surgery. At the one-year follow-up, both groups reported similar improvements in pain and function, suggesting that the placebo effect played a significant role in the perceived benefits of the actual surgery.
Comparison of Subacromial Decompression Surgery with Exercise Therapy
Several studies have compared subacromial decompression surgery with exercise therapy programs for patients with chronic shoulder pain.
The findings consistently demonstrate that exercise therapy is at least as effective as surgery, and in some cases, may even provide better long-term outcomes.
Overall, the current evidence from systematic reviews, meta-analyses, and high-quality randomised controlled trials suggests that subacromial decompression surgery offers no significant advantages over placebo or exercise therapy for treating chronic shoulder pain. These findings have led to a re-evaluation of the role of this surgical procedure in the management of subacromial pain syndrome.
Risks and Complications of Subacromial Decompression Surgery
Subacromial decompression surgery, like any surgical procedure, carries inherent risks and potential complications. While the surgery is generally considered safe, patients should be aware of the potential for serious harm.
One of the most concerning risks is infection. Despite stringent sterilisation protocols, there is always a chance of introducing bacteria into the surgical site, which can lead to deep tissue infections. These infections can be challenging to treat and may require additional surgical interventions or prolonged antibiotic therapy.
Another significant risk is nerve injury. The surgical area is in close proximity to several important nerves, including the axillary nerve and the musculocutaneous nerve. Inadvertent damage to these nerves during the procedure can result in numbness, weakness, or paralysis in the affected areas, potentially leading to long-term functional impairment.
Other potential complications include excessive bleeding, blood clots, shoulder stiffness or frozen shoulder, and failure to alleviate the original shoulder pain.
In some cases, patients may experience worsening of their symptoms or develop new issues, such as shoulder instability or rotator cuff tears.
While the overall complication rate for subacromial decompression surgery is relatively low, ranging from 5% to 15% in most studies, the consequences of these complications can be severe and life-altering. It is crucial for patients to carefully weigh the potential risks against the anticipated benefits and to have realistic expectations about the outcome of the surgery.
Long-term Outcomes following subacromial decompression surgery
The long-term outcomes of subacromial decompression surgery are crucial in evaluating its effectiveness and determining whether the potential risks and complications are justified. Recent studies have examined the impact of this procedure on pain levels, shoulder function, and overall quality of life for patients up to five years after the surgery.
Numerous systematic reviews and meta-analyses have consistently shown that subacromial decompression surgery offers no significant long-term benefits over placebo surgery or non-surgical treatments, such as exercise therapy. Patients who underwent the surgery reported similar levels of pain, shoulder function, and quality of life as those who received a placebo procedure or engaged in exercise programs.
In fact, some research suggests that non-surgical treatments, particularly exercise therapy, may lead to better long-term outcomes compared to subacromial decompression surgery. Patients who participated in structured exercise programs often experienced greater improvements in pain reduction, increased range of motion, and enhanced functional abilities, even years after completing the therapy.
It is important to note that while subacromial decompression surgery may provide short-term relief for some patients, the long-term benefits appear to be limited. The risks associated with the procedure, including potential complications like infection and nerve injury, should be carefully weighed against the lack of substantial long-term improvements in pain, function, and quality of life.
Clinical Recommendations for shoulder pain and subacromial decompression surgery
Recent reviews have provided compelling evidence against the routine use of subacromial decompression surgery for the treatment of shoulder pain lasting more than three months. The findings consistently demonstrate that this surgical intervention offers no significant benefits over placebo surgery or exercise therapy in terms of pain reduction, functional improvement, or quality of life enhancement.
Based on the current body of research, several leading medical organisations, including the British Medical Journal and the Danish Health Authority, have issued recommendations advising against the use of subacromial decompression surgery as a first-line treatment for chronic shoulder pain. These recommendations emphasise the importance of exploring non-surgical options, such as exercise therapy, before considering invasive procedures.
Clinical guidelines emphasise the importance of adopting a conservative approach, focusing on non-surgical treatments such as exercise therapy, physical therapy, and pain management strategies. These non-invasive methods have been shown to be effective in reducing pain and improving function while minimising the risks associated with surgical interventions.
In summary, the latest scientific evidence strongly recommends against the routine use of subacromial decompression surgery for the treatment of chronic shoulder pain lasting more than three months.
Healthcare professionals are encouraged to prioritise non-surgical options and to carefully consider the potential risks and limited benefits of this surgical procedure before recommending it to patients.
Alternative Treatments for Shoulder Pain other than subacromial decompression surgery
Exercise therapy has emerged as a highly effective and low-risk alternative for managing chronic shoulder pain.
Numerous studies have demonstrated the benefits of a structured exercise program, which typically includes a combination of stretching, strengthening, and range-of-motion exercises tailored to the individual's needs.
One of the primary advantages of exercise therapy is its ability to address the underlying causes of shoulder pain, such as muscle imbalances, poor posture, and joint stiffness. By strengthening the rotator cuff and surrounding muscles, exercise can improve shoulder stability and reduce the stress on the affected area, leading to a reduction in pain and improved function.
In addition to exercise therapy, other non-surgical options for shoulder pain include:
- Physiotherapy: A comprehensive physiotherapy program can incorporate manual therapy techniques, such as soft tissue mobilisation and joint mobilisation, to improve mobility and alleviate pain.
- Corticosteroid injections: These injections can provide temporary relief from inflammation and pain, allowing for better engagement in exercise and physical therapy programs.
- Oral anti-inflammatory medications: Over-the-counter or prescription anti-inflammatory drugs can help manage pain and inflammation, particularly in the short term.
- Activity modification: Adjusting daily activities and avoiding movements that exacerbate pain can help prevent further injury and promote healing.
Conclusion
Subacromial decompression surgery has long been a common treatment for persistent shoulder pain, but the latest evidence calls into question its effectiveness and safety. Systematic reviews and meta-analyses have consistently shown that the surgery offers no significant benefits over placebo or exercise therapy in terms of pain reduction, improved function, or quality of life. Furthermore, the procedure carries a risk of serious complications, including infection, nerve injury, and prolonged recovery.
While the surgery may still be appropriate in certain specific cases, the current evidence suggests that it should not be routinely recommended or performed for shoulder pain lasting more than three months. Instead, healthcare professionals should prioritise non-surgical treatments, such as exercise therapy, physiotherapy, and other conservative approaches, which have been shown to be effective and carry a lower risk of harm.
Patients should be fully informed about the risks and limited benefits of subacromial decompression surgery and encouraged to explore alternative treatment options in consultation with their healthcare providers.
Healthcare professionals, in turn, should review and update their clinical practices to align with the latest research findings and prioritise evidence-based treatments that prioritise patient safety and long-term outcomes.
Ultimately, the decision to undergo subacromial decompression surgery should be made cautiously and only after careful consideration of the potential risks and benefits, as well as the availability of effective non-surgical alternatives.
