Patient-Oriented Evidence That Matters

Surgery Equal to No Surgery for Patients with Subacromial Shoulder Pain


Am Fam Physician. 2018 Jul 1;98(1):54.

Clinical Question

Do patients with subacromial shoulder pain for at least three months who are treated surgically have better outcomes than those who are treated without surgery?

Bottom Line

In patients with subacromial shoulder pain of at least three months' duration who receive physical therapy, surgical decompression is no better than arthroscopy without decompression in improving pain or function, and neither is much better than no invasive intervention at all. (Level of Evidence = 1b)


These authors randomized adults with subacromial pain of at least three months' duration into one of three groups: arthroscopic decompression of the acromion (n = 106), arthroscopy without decompression (n = 103), or no additional treatment (n = 104). Before enrollment, all patients underwent physical therapy and had at least one corticosteroid injection. The authors excluded patients with complete rotator cuff tears. A healthy percentage of the patients allocated to decompression, arthroscopy only, and no treatment (23%, 42%, and 12%, respectively) did not receive their assigned treatment by six months because they were already better. Additionally, approximately 15% of the patients did not complete 12 months of follow-up. After six months and one year, the patients treated with surgical decompression or arthroscopy without decompression had improvements in pain and function (as measured by the Oxford Shoulder Score) compared with patients who received no treatment, but the differences were not clinically important. Additionally, there was no difference between the decompression and arthroscopy without decompression groups. Two patients in each group developed adhesive capsulitis. The authors did not report on surgical complications.

Study design: Randomized controlled trial (double-blinded)

Funding source: Government

Allocation: Concealed

Setting: Outpatient (specialty)

Reference: Beard DJ, Rees JL, Cook JA, et al. Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW): a multicentre, pragmatic, parallel group, placebo-controlled, three-group, randomised surgical trial. Lancet. 2018;391(10118):329–338.

POEMs (patient-oriented evidence that matters) are provided by EssentialEvidence Plus, a point-of-care clinical decision support system published by Wiley-Blackwell. For more information, please see http://www.essentialevidenceplus.com. Copyright Wiley-Blackwell. Used with permission.

For definitions of levels of evidence used in POEMs, see https://www.essentialevidenceplus.com/product/ebm_loe.cfm?show=oxford.

To subscribe to a free podcast of these and other POEMs that appear in AFP, search in iTunes for “POEM of the Week” or go to http://goo.gl/3niWXb.

This series is coordinated by Sumi Sexton, MD, Editor-in-Chief.

A collection of POEMs published in AFP is available at https://www.aafp.org/afp/poems.



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