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Am Fam Physician. 2019;99(3):190

Clinical Question

In patients with symptoms of shoulder impingement syndrome, is subacromial decompression surgery more effective than sham arthroscopy or exercise therapy to decrease pain and improve function?

Bottom Line

Despite being one of the most common orthopedic surgeries performed, subacromial decompression is not significantly better than physical therapy to treat patients with pain and limited function caused by shoulder impingement. This study is backed up by a meta-analysis that found the same results (Disabil Rehabil. 2015;37(1):1–8). Another meta-analysis (Br J Sports Med. 2017;51(18):1340–1347) demonstrated the benefit of shoulder exercises over other physical therapy modalities. (Level of Evidence = 1a)

Synopsis

Finnish researchers enrolled 210 adults 35 to 65 years of age with a clinical presentation of shoulder impingement syndrome, who had no evidence of rotator cuff tear on magnetic resonance imaging and who had not responded to three months of conventional treatment. The patients were first randomized to receive surgery or physical therapy using concealed allocation. Patients in the surgery group underwent diagnostic arthroscopy to rule out tears or other pathology and then, in the operating room, were randomized again to receive arthroscopic subacromial decompression or no further intervention (to keep treatment assignments concealed, the latter group was kept in the operating theater for the length of time of a typical decompression). After two years, patients in all three groups had a large decrease in reported pain, from approximately 75 points to between 20 and 30 points on a 100-point visual analog scale. Decompression was statistically better than exercise therapy, but the result would not be clinically relevant (a difference of at least 15 points) and was no different than diagnostic arthroscopy. There was also no difference in pain or function scores at earlier time points. The researchers did not attempt to stratify patients by degree of joint narrowing or by the presence of osteoarthritis or other morphology, and targeted therapy aimed at specific changes may have found a difference in treatment outcomes.

Study design: Randomized controlled trial (double-blinded)

Funding source: Government

Allocation: Concealed

Setting: Outpatient (specialty)

Reference:PaavolaMMalmivaaraATaimelaSet alFinnish Subacromial Impingement Arthroscopy Controlled Trial (FIMPACT) InvestigatorsSubacromial decompression versus diagnostic arthroscopy for shoulder impingement: randomised, placebo surgery controlled clinical trial. BMJ2018;362k2860.

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

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