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Is arthroscopic subacromial decompression effective for shoulder impingement?
It’s impossible to say for certain in the absence of randomized controlled trials. However, in patients whose impingement symptoms don’t improve after 3 to 6 months, arthroscopic subacromial decompression (ASD) is associated with modest (about 10%) long-term improvement in pain and function compared with open acromioplasty or baseline (strength of recommendation [SOR]: B, cohort studies).
Patients older than 57 years may do better with surgery than physical therapy (SOR: B, single cohort study).
EVIDENCE SUMMARY
Six cohort studies found that patients who underwent ASD for subacromial impingement had improved pain and function scores at 4.5 to 12 years after surgery (TABLE1-7). Weaknesses of the overall data set include use of heterogeneous outcome measures across studies, lack of sham surgical controls, and lack of blinding.
ASD improves pain and function slightly more than other treatments
One prospective and one retrospective cohort trial compared ASD with another intervention. In the prospective trial, ASD was associated with a 10% better combined pain and function score than open acromioplasty at 12 years.1 In the retrospective trial, ASD was also associated with a 10% better combined pain and function score than prolonged physical therapy in patients older than 57 years (the median age of study participants) but not patients younger than 57 years.2
Two other studies found improvements in pain and function
Two other prospective cohort studies didn’t use a comparison group but followed changes in standardized shoulder pain and function scores for 5 to 6 years after ASD. In one study, pain decreased 6 points on a 10-point visual analog scale by 6 months postop (P<.001).3 In both studies, a 9% to 10% improvement in function was seen between 6 months and 5 to 6 years after surgery.3,4
A third cohort study that asked patients about overall pain and satisfaction 8 to 11 years after ASD found that most were “very” or “quite” satisfied and half were pain-free.5,6
Rotator cuff tears found less likely with ASD
An anatomic study obtained ultrasounds of patients 13 to 17 years after ASD and compared the findings to rotator cuff ultrasounds of the general population.7 Patients who had ASD were 22% less likely to demonstrate rotator cuff tears at the end of the study (no statistics were reported to measure significance).
RECOMMENDATIONS
Guidelines from the Washington State Department of Labor and Industry state that patients who should undergo isolated subacromial decompression (with or without acromioplasty) need to have documented subacromial impingement syndrome with magnetic resonance imaging evidence of rotator cuff tendonopathy or tear, have undergone 12 weeks of conservative therapy (including at least active assisted range of motion and home-based exercises), and have had a subacromial injection with a local anesthetic that has provided documented relief of pain.8
No current guidelines are available from national or international orthopedic or sports medicine organizations.
1. Odenbring S, Wagner P, Atroshi I. Long-term outcomes of arthroscopic acromioplasty of chronic shoulder impingement syndrome: a prospective cohort study with a minimum of 12 years’ follow-up. Arthroscopy. 2008;24:1092–1098.
2. Biberthaler P, Beirer M, Kirchhoff S, et al. Significant benefit for older patients after arthroscopic subacromial decompression: a long-term follow-up study. Int Orthop. 2013;37:457–462.
3. Lunsjo K, Bengtsson M, Nordqvist A, et al. Patients with shoulder impingement remain satisfied 6 years after arthroscopic subacromial decompression. Acta Orthop. 2011;82:711–713.
4. Dom K, Van Glabbeek F, Van Riet RP, et al. Arthroscopic subacromial decompression for advanced (stage II) impingement syndrome: a study of 52 patients with 5 year follow-up. Acta Orthop Belg. 2003;69:13–17.
5. Klintberg IH, Karlsson J, Svantesson U. Health-related quality of life, patient satisfaction, and physical activity 8–11 years after arthroscopic subacromial decompression. J Shoulder Elbow Surg. 2011;20:598–608.
6. Klintberg IH, Svantesson U, Karlsson J. Long-term patient satisfaction and functional outcome 8-11 years after subacromial decompression. Knee Surg Sports Traumatol Arthrosc. 2010;18:394–403.
7. Bjornsson H, Norlin R, Knutsson A, et al. Fewer rotator cuff tears fifteen years after arthroscopic subacromial decompression. J Shoulder Elbow Surg. 2010;19:111–115.
8. Washington State Department of Labor and Industries. Shoulder Conditions Diagnosis and Treatment Guideline. Available at: http://www.lni.wa.gov/ClaimsIns/Files/OMD/MedTreat/FINALguidelineShoulderConditionsOct242013.pdf. Accessed October 20, 2015.
It’s impossible to say for certain in the absence of randomized controlled trials. However, in patients whose impingement symptoms don’t improve after 3 to 6 months, arthroscopic subacromial decompression (ASD) is associated with modest (about 10%) long-term improvement in pain and function compared with open acromioplasty or baseline (strength of recommendation [SOR]: B, cohort studies).
Patients older than 57 years may do better with surgery than physical therapy (SOR: B, single cohort study).
EVIDENCE SUMMARY
Six cohort studies found that patients who underwent ASD for subacromial impingement had improved pain and function scores at 4.5 to 12 years after surgery (TABLE1-7). Weaknesses of the overall data set include use of heterogeneous outcome measures across studies, lack of sham surgical controls, and lack of blinding.
ASD improves pain and function slightly more than other treatments
One prospective and one retrospective cohort trial compared ASD with another intervention. In the prospective trial, ASD was associated with a 10% better combined pain and function score than open acromioplasty at 12 years.1 In the retrospective trial, ASD was also associated with a 10% better combined pain and function score than prolonged physical therapy in patients older than 57 years (the median age of study participants) but not patients younger than 57 years.2
Two other studies found improvements in pain and function
Two other prospective cohort studies didn’t use a comparison group but followed changes in standardized shoulder pain and function scores for 5 to 6 years after ASD. In one study, pain decreased 6 points on a 10-point visual analog scale by 6 months postop (P<.001).3 In both studies, a 9% to 10% improvement in function was seen between 6 months and 5 to 6 years after surgery.3,4
A third cohort study that asked patients about overall pain and satisfaction 8 to 11 years after ASD found that most were “very” or “quite” satisfied and half were pain-free.5,6
Rotator cuff tears found less likely with ASD
An anatomic study obtained ultrasounds of patients 13 to 17 years after ASD and compared the findings to rotator cuff ultrasounds of the general population.7 Patients who had ASD were 22% less likely to demonstrate rotator cuff tears at the end of the study (no statistics were reported to measure significance).
RECOMMENDATIONS
Guidelines from the Washington State Department of Labor and Industry state that patients who should undergo isolated subacromial decompression (with or without acromioplasty) need to have documented subacromial impingement syndrome with magnetic resonance imaging evidence of rotator cuff tendonopathy or tear, have undergone 12 weeks of conservative therapy (including at least active assisted range of motion and home-based exercises), and have had a subacromial injection with a local anesthetic that has provided documented relief of pain.8
No current guidelines are available from national or international orthopedic or sports medicine organizations.
It’s impossible to say for certain in the absence of randomized controlled trials. However, in patients whose impingement symptoms don’t improve after 3 to 6 months, arthroscopic subacromial decompression (ASD) is associated with modest (about 10%) long-term improvement in pain and function compared with open acromioplasty or baseline (strength of recommendation [SOR]: B, cohort studies).
Patients older than 57 years may do better with surgery than physical therapy (SOR: B, single cohort study).
EVIDENCE SUMMARY
Six cohort studies found that patients who underwent ASD for subacromial impingement had improved pain and function scores at 4.5 to 12 years after surgery (TABLE1-7). Weaknesses of the overall data set include use of heterogeneous outcome measures across studies, lack of sham surgical controls, and lack of blinding.
ASD improves pain and function slightly more than other treatments
One prospective and one retrospective cohort trial compared ASD with another intervention. In the prospective trial, ASD was associated with a 10% better combined pain and function score than open acromioplasty at 12 years.1 In the retrospective trial, ASD was also associated with a 10% better combined pain and function score than prolonged physical therapy in patients older than 57 years (the median age of study participants) but not patients younger than 57 years.2
Two other studies found improvements in pain and function
Two other prospective cohort studies didn’t use a comparison group but followed changes in standardized shoulder pain and function scores for 5 to 6 years after ASD. In one study, pain decreased 6 points on a 10-point visual analog scale by 6 months postop (P<.001).3 In both studies, a 9% to 10% improvement in function was seen between 6 months and 5 to 6 years after surgery.3,4
A third cohort study that asked patients about overall pain and satisfaction 8 to 11 years after ASD found that most were “very” or “quite” satisfied and half were pain-free.5,6
Rotator cuff tears found less likely with ASD
An anatomic study obtained ultrasounds of patients 13 to 17 years after ASD and compared the findings to rotator cuff ultrasounds of the general population.7 Patients who had ASD were 22% less likely to demonstrate rotator cuff tears at the end of the study (no statistics were reported to measure significance).
RECOMMENDATIONS
Guidelines from the Washington State Department of Labor and Industry state that patients who should undergo isolated subacromial decompression (with or without acromioplasty) need to have documented subacromial impingement syndrome with magnetic resonance imaging evidence of rotator cuff tendonopathy or tear, have undergone 12 weeks of conservative therapy (including at least active assisted range of motion and home-based exercises), and have had a subacromial injection with a local anesthetic that has provided documented relief of pain.8
No current guidelines are available from national or international orthopedic or sports medicine organizations.
1. Odenbring S, Wagner P, Atroshi I. Long-term outcomes of arthroscopic acromioplasty of chronic shoulder impingement syndrome: a prospective cohort study with a minimum of 12 years’ follow-up. Arthroscopy. 2008;24:1092–1098.
2. Biberthaler P, Beirer M, Kirchhoff S, et al. Significant benefit for older patients after arthroscopic subacromial decompression: a long-term follow-up study. Int Orthop. 2013;37:457–462.
3. Lunsjo K, Bengtsson M, Nordqvist A, et al. Patients with shoulder impingement remain satisfied 6 years after arthroscopic subacromial decompression. Acta Orthop. 2011;82:711–713.
4. Dom K, Van Glabbeek F, Van Riet RP, et al. Arthroscopic subacromial decompression for advanced (stage II) impingement syndrome: a study of 52 patients with 5 year follow-up. Acta Orthop Belg. 2003;69:13–17.
5. Klintberg IH, Karlsson J, Svantesson U. Health-related quality of life, patient satisfaction, and physical activity 8–11 years after arthroscopic subacromial decompression. J Shoulder Elbow Surg. 2011;20:598–608.
6. Klintberg IH, Svantesson U, Karlsson J. Long-term patient satisfaction and functional outcome 8-11 years after subacromial decompression. Knee Surg Sports Traumatol Arthrosc. 2010;18:394–403.
7. Bjornsson H, Norlin R, Knutsson A, et al. Fewer rotator cuff tears fifteen years after arthroscopic subacromial decompression. J Shoulder Elbow Surg. 2010;19:111–115.
8. Washington State Department of Labor and Industries. Shoulder Conditions Diagnosis and Treatment Guideline. Available at: http://www.lni.wa.gov/ClaimsIns/Files/OMD/MedTreat/FINALguidelineShoulderConditionsOct242013.pdf. Accessed October 20, 2015.
1. Odenbring S, Wagner P, Atroshi I. Long-term outcomes of arthroscopic acromioplasty of chronic shoulder impingement syndrome: a prospective cohort study with a minimum of 12 years’ follow-up. Arthroscopy. 2008;24:1092–1098.
2. Biberthaler P, Beirer M, Kirchhoff S, et al. Significant benefit for older patients after arthroscopic subacromial decompression: a long-term follow-up study. Int Orthop. 2013;37:457–462.
3. Lunsjo K, Bengtsson M, Nordqvist A, et al. Patients with shoulder impingement remain satisfied 6 years after arthroscopic subacromial decompression. Acta Orthop. 2011;82:711–713.
4. Dom K, Van Glabbeek F, Van Riet RP, et al. Arthroscopic subacromial decompression for advanced (stage II) impingement syndrome: a study of 52 patients with 5 year follow-up. Acta Orthop Belg. 2003;69:13–17.
5. Klintberg IH, Karlsson J, Svantesson U. Health-related quality of life, patient satisfaction, and physical activity 8–11 years after arthroscopic subacromial decompression. J Shoulder Elbow Surg. 2011;20:598–608.
6. Klintberg IH, Svantesson U, Karlsson J. Long-term patient satisfaction and functional outcome 8-11 years after subacromial decompression. Knee Surg Sports Traumatol Arthrosc. 2010;18:394–403.
7. Bjornsson H, Norlin R, Knutsson A, et al. Fewer rotator cuff tears fifteen years after arthroscopic subacromial decompression. J Shoulder Elbow Surg. 2010;19:111–115.
8. Washington State Department of Labor and Industries. Shoulder Conditions Diagnosis and Treatment Guideline. Available at: http://www.lni.wa.gov/ClaimsIns/Files/OMD/MedTreat/FINALguidelineShoulderConditionsOct242013.pdf. Accessed October 20, 2015.
Evidence-based answers from the Family Physicians Inquiries Network