Subacromial decompression surgery for adults with shoulder pain: a clinical practice guideline

Abstract

Clinical questionDo adults with atraumatic shoulder pain for more than 3 months diagnosed as subacromial pain syndrome (SAPS), also labelled as rotator cuff disease, benefit from subacromial decompression surgery? This guideline builds on to two recent high quality trials of shoulder surgery.Current practiceSAPS is the common diagnosis for shoulder pain with several first line treatment options, including analgesia, exercises, and injections. Surgeons frequently perform arthroscopic subacromial decompression for prolonged symptoms, with guidelines providing conflicting recommendations.RecommendationThe guideline panel makes a strong recommendation against surgery.How this guideline was createdA guideline panel including patients, clinicians, and methodologists produced this recommendation in adherence with standards for trustworthy guidelines and the GRADE system. The recommendation is based on two linked systematic reviews on (a) the benefits and harms of subacromial decompression surgery and (b) the minimally important differences for patient reported outcome measures. Recommendations are made actionable for clinicians and their patients through visual overviews. These provide the relative and absolute benefits and harms of surgery in multilayered evidence summaries and decision aids available in MAGIC (www.magicapp.org) to support shared decisions and adaptation.The evidenceSurgery did not provide important improvements in pain, function, or quality of life compared with placebo surgery or other options. Frozen shoulder may be more common with surgery.Understanding the recommendationThe panel concluded that almost all informed patients would choose to avoid surgery because there is no benefit but there are harms and it is burdensome. Subacromial decompression surgery should not be offered to patients with SAPS. However, there is substantial uncertainty in what alternative treatment is best.

Musculoskeletal healthcare: Have we over‐egged the pudding?

“…A good example of medical overuse driven by overdetection would be acting upon the incidental findings commonly found with musculoskeletal imaging (eg lumbar disc degeneration, rotator cuff tear, femoroacetabular impingement, heel spur) and initiating more intensive treatment for the patient (eg specialist referral, surgery). What compounds the problem is that many of the surgeries that are encouraged (eg knee arthroscopy, subacromial decompression) are now known to be no more effective than placebo. In all these cases the medical overuse is triggered by an unwarranted diagnosis.…”

General practice management of rotator cuff related shoulder pain: A reliance on ultrasound and injection guided care

“…Between 65% and 80% of people with RCRP, even with rotator cuff tears, recover (large improvement or complete recovery) with exercise [14]. There are no clinically important benefits of surgery over exercise for RCRP [15][16][17][18]. Given it is less expensive and there are less serious risks, it is logical that exercise is recommended prior to surgery.…”

Galt kan være rett

“…Dette inngrepet står også på Bent Høies liste. Anbefalt retningslinje er å ikke vurdere operasjon før adekvat ikke-operativ behandling er prøvd i minst tre måneder (3). Dette er også anbefalingen fra Norsk forening for skulder-og albuekirurgi, en faggruppe i Norsk ortopedisk forening.…”