Arthroscopic subacromial decompression may not improve shoulder impingement at 5 years
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Published results showed patients with shoulder impingement syndrome who underwent arthroscopic subacromial decompression had no clinically relevant improvements at 5-year follow-up compared with diagnostic arthroscopy or exercise therapy.
Researchers randomly assigned 210 patients 35 to 65 years of age who had symptoms consistent with shoulder impingement syndrome for more than 3 months to undergo either exercise therapy or surgery. In addition, researchers randomly assigned patients in the surgery group to receive either arthroscopic subacromial decompression or diagnostic arthroscopy. Researchers measured shoulder pain at rest and on arm activity using the VAS score, and collected the Constant-Murley, simple shoulder test, SF-36 and 15D health-related quality of life questionnaire scores at baseline and 3, 6, 12, 24 months and 5 years after randomization.
Overall, 83% of patients completed the 5-year follow-up, with 62 patients in the exercise therapy group, 55 patients in the diagnostic arthroscopy group and 53 patients in the arthroscopic subacromial decompression group. Results showed no between-group differences that exceeded the minimally important difference for VAS pain scores at rest or on arm activity among patients who underwent arthroscopic subacromial decompression or diagnostic arthroscopy. Researchers also found no between-group differences between arthroscopic subacromial decompression and diagnostic arthroscopy in shoulder function, health-related quality of life or adverse events that exceeded the minimally important difference.
Patients who received arthroscopic subacromial decompression vs. exercise therapy had a mean difference in VAS pain scores of 1 at rest and –3.9 on arm activity, according to results. Researchers noted no significant between-group differences between arthroscopic subacromial decompression and exercise therapy for shoulder function, health-related quality of life or adverse events.
“The findings contest the current practice of performing subacromial decompression in patients with shoulder impingement syndrome and lend further support to existing guidelines that make a strong recommendation against surgery as a treatment for patients with subacromial pain,” the authors wrote. “As the current evidence indicates that the impingement theory has become antiquated, we would also recommend to abandon the term shoulder impingement as it refers to this mechanical theory. The more generic term ‘subacromial pain’ should be preferred.”
Perspective
Back to TopGrant E. Garrigues, MD, and Ryan J. Quigley, MD, PhD
Subacromial impingement remains one of the most common diagnoses given to patients with a painful shoulder. Subacromial decompression is an attempt to remove the anterior acromial “spur” (an enthesophyte in the coracoacromial ligament) in an attempt to diminish subacromial contact. This surgical procedure continues to remain one of the most commonly performed orthopedic surgical procedures annually. Despite this, many studies have shown minimal benefit from subacromial decompression compared with physical therapy alone and the procedure remains controversial.
This randomized controlled trial from Finland is a well-powered study of 210 participants with 5-year follow-up randomized to physical therapy alone, surgical treatment with diagnostic arthroscopy alone (sham surgery) or surgical intervention with subacromial decompression. Overall, there was no difference in patient functional outcome or pain levels between any of the groups. This study further solidifies the extensive body of evidence that the “spur” of the acromion is simply a traction enthesophyte at the acromial attachment of the coracoacromial ligament and is not the cause of pathology.
As the evidence continues to mount, hopefully isolated subacromial decompression, a surgery that consistently is shown to provide no benefit over physical therapy and sham treatments, will cease to exist.
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