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Subacromial pain syndrome, a collection of common shoulder complaints, is often treated with surgery. New research shows that this surgery does nothing more than a placebo.
Subacromial pain syndrome (SAPS)
Subacromial pain syndrome, formerly known as shoulder impingement, is a collection of shoulder complaints that arise in the same space in the shoulder joint. The acromion is also called the ‘shoulder roof.’ Below the acromion (‘subacromial’), between the collarbone and the head of the upper arm, there is a space where complaints often arise.
In this space, we find a bursa, attachments of muscles (rotator cuff and long head of biceps), and cartilage. When friction occurs here, irritation, damaged tendons, and inflammation can follow in one or more of these. The well-known shoulder complaints of, for example, painters. These are often caused by making this space even smaller when the arms are placed above shoulder level.
In a separate article about these shoulder complaints, I elaborate on this. I also mention tests to possibly determine the cause of the complaints. Although the article is already 5 years old, there are still plenty of questions coming in from people with shoulder complaints. That is an indication of how common these complaints are. Recently, I also went into more detail about the effect of a corticosteroid injection for shoulder complaints.
Surgery for shoulder complaints.
In this article, I discuss recent research into one of the possible treatments to relieve complaints from SAPS. Surgeons can enlarge this subacromial space through a (keyhole) operation (‘subacromial decompression of the shoulder’) [1]. This can reduce friction, irritation, and inflammation in the mentioned attachments, bursa, and cartilage.
That’s at least the idea.
A panel of 20 experts recently concluded, however, that this procedure is ineffective and offers too much chance of adverse effects [2]
Clinicians should not offer patients subacromial decompression surgery unprompted, and clinicians, public healthcare providers, and others should make efforts to educate the public regarding the ineffectiveness of surgery
They reached this judgment based on a review of several studies, including a large British study from 2017 [3].
“Benefits of shoulder surgery are in the patient’s head”
In the 2017 study, a trial was conducted with three groups of patients. The patients came from 32 British hospitals with 51 involved surgeons. The 313 patients had at least 3 months of subacromial complaints. It had already been established that the tendons of the rotator cuff were intact. They had all already had a non-operative treatment. In addition to, for example, physiotherapy, they had also already received at least one steroid injection.
The researchers divided the patients into three treatment groups:
- Keyhole surgery with subacromial decompression.
- Only keyhole surgery (as a placebo).
- No treatment, only assessment by a shoulder specialist.
The patients in the two groups that were operated on were not told whether this was only the keyhole surgery or also a procedure. The patients were followed up after 6 months and a year.
After 6 months, there was no difference in self-reported pain complaints in both groups that were operated on. Both showed a slightly better effect on pain complaints than the group that had not received treatment. However, this difference was so small that it was not clinically significant. Since there was no difference between the two surgery groups, the researchers consider a placebo effect.
New British guidelines for shoulder surgery
Based in part on this 2017 research, the
British Medical Journal has now proposed new guidelines. They strongly advise against the surgical procedure. Unfortunately, they cannot give a clear recommendation on alternatives. That’s not very surprising either. In the recent article about corticosteroids, I compare such an injection with physiotherapy and manual therapy for these shoulder complaints. The conclusion was that it is unclear whether an injection in the longer term (6 months to a year) offers more success than therapy or no treatment. Also in the 2017 study, we see that clients had already tried both treatments when they sought their salvation in surgery. The conclusion is therefore quite annoying: Shoulder complaints, specifically
subacromial pain syndrome, remain a difficult problem without a clear winner in treatment.
Sources
- mznl.be/sites/default/files/brochures/subacromiale_decompressie_van_de_schouder.pdf
- independent.co.uk/news/health/shoulder-impingement-surgery-rotator-cuff-bmj-guideline-doctor-a8766116.html
- thelancet.com/journals/lancet/article/PIIS0140-6736(17)32457-1/fulltext
