Issues with Shoulder Impingement surgery

Shoulder impingement results in pain with lifting your arm above your head. The typical surgery for this involves shaving the acromion bone to make more room for the rotator cuff to more freely move. But does this surgery work?

A recent article from the British Journal of Sports Medicine shows that shoulder impingement surgery is no better than physical therapy alone or a diagnostic procedure where no intervention is done.

What does this mean to you if you have shoulder impingement?
-You can likely skip surgery and maximize the nonsurgical alternatives for your shoulder pain.
-Get a specific and accurate diagnosis from a physician who focuses on shoulder and musculoskeletal issues.
-Have a diagnostic musculoskeletal ultrasound of your shoulder to evaluate for rotator cuff tear and instability.
-Maximize exercise options including physical therapy.
-If inadequate, consider a regenerative medicine treatment to improve stability of the shoulder that is causing impingement. Also improve the shoulder by optimizing it’s biologic health, reduce inflammation, and improve the neuromuscular components.

Paavola M, Kanto K, Ranstam J, et al Subacromial decompression versus diagnostic arthroscopy for shoulder impingement: a 5-year follow-up of a randomised, placebo surgery controlled clinical trial British Journal of Sports Medicine  Published Online First: 05 October 2020.

***For evaluation and treatment at Chicago Arthritis and Regenerative Medicine:

– Hello, this is Siddharth Tambar from Chicago Arthritis and Regenerative Medicine. It’s October 12th, 2020. Welcome to our weekly educational meeting. This is live streaming currently. And on this meeting, weekly, I’m discussing concepts related to what we do here at Chicago Arthritis and Regenerative Medicine, answering questions that I frequently get from staff and patients, and also discussing just general big picture musculoskeletal concepts in terms of how we’re trying to treat people and get people better here. As a reminder, we’re focused on nonsurgical management of arthritis, tendonitis injuries, and back pain. And so it’s an interesting time because there’s a ton of information that’s coming out progressively about comparative studies, what works, what doesn’t work. There’s an interesting article that came out in the British Journal of Sports Medicine recently about shoulder impingement surgery. So shoulder impingement essentially means that when you’re trying to lift your arm up, that it catches and causes pain and dysfunction. So the traditional surgical approach to that was to do what’s called subacromial decompression or acromioplasty, and what that means is going to the bone, the acomion that sits over the rotator cuff, shaving it down to, in theory, put a little bit of more space for the rotator cuff to flow a little bit easier. It’s an interesting idea. May make sense from a surgical and structural standpoint, but in the last few years, there’s been progressive evidence that that may not be better than physical therapy. So in the British Journal of Sports Medicine, an article recently published by a group of physicians from Finland basically compared the effectiveness of this surgery in a interesting and unique way. They essentially took 175 patients who had shoulder impingement, and that was defined by reduced range of motion with abduction, internal rotation, and that was diagnosed clinically. They made sure that they took out patients who already had a significant rotator cuff tear or a significant osteoarthritis. They gave them a diagnostic injection meaning injecting some local anesthetic into the shoulder bursa space. And if they had a significant improvement in pain indicated that they had shoulder impingement and then included them in this study. The idea being that they wanted to kind of exclude out people that may have neck issues or some other issues, and really focused in on this category of patients. They split them up into three different groups. The first one being patients who progressed with shoulder acromioplasty, the surgery. The second were patients that had a diagnostic arthroscopy. And that means that they had a surgical procedure, but it was strictly one that was looking at what’s actually going on in the shoulder, not one that was actually doing any additional intervention. And number three, they also looked at a group of patients that also had just physical therapy. So in all of these patients had already failed some kind of exercise therapy and they excluded out those other patients that I mentioned and they then compared the effectiveness of the interventions. And so the patients that had surgery, subacromial decompression, they found that there was no significant improvement compared to the patients who just had the diagnostic arthroscopy or the patients that had just physical therapy. And they followed them out over five years and found that there was no difference during that time. Really interesting. Why is this important? Number one, if you compare surgery to nonsurgical treatments, there’s higher risk associated with surgery, whether that’s due to anesthetic risk, conscious sedation risk, nerve block risk, bleeding, tissue damage, other kinds of issues like that. There’s just higher risk than anything that’s nonsurgical. So if surgery is not more useful, then why go that route, right? Always consider other options. The other interesting component here is that the structural model of musculoskeletal care, which says look at your x-ray, you may have a little bone spur. We need to shave that off, but that does not seem to play out as well as people think it does. It may make some intuitive sense but that’s not actually how the body works. Understand that arthritis, tendonitis, is more of a biologic functional issue, and not as much of a strictly structural model of care is important. And it’s likely the reason why in this study that even though they did an intervention, the subacromial acromioplasty, the surgery, there was no additional benefit compared to just a diagnostic procedure and compared to just physical therapy. So super, super important to understand that. And so then it comes down to, what are your nonsurgical options and alternatives for shoulder pain from impingement? So number one absolutely, you need to maximize physical therapy. Exercise therapy is humongous. Doing the right exercises is really important. If that fails, however, number two, you then need to determine, do you have some other cause for this kind of problem? Do you have a rotator cuff tear? Do you have any significant arthritis involved? I would recommend getting that evaluated with a diagnostic musculoskeletal ultrasound. Under a trained hand you can really find some very fine details in this regard. Number three, you want to then also determine is there any kind of neck issue going on? And the reason why is because if you have a neck issue, it can really look a lot like a shoulder issue as well. So you want to make sure you’re not possibly confusing these. And then number four is if there’s no other significant rotator cuff or osteoarthritic process that I would recommend a treatment like platelet rich plasma treatment if you’re still having pain. The key here to understand is that you don’t want to just inject that into the bursa around the rotator cuff. You want to do better than that. Number one, if there’s any even mild fraying of the rotator cuff, you want to make sure to treat that. Number two, if there’s any evidence of strain on the AC joint, essentially the joint where the rotator cuff runs underneath. If there’s any evidence of strain on that, either on examination where you’re having symptoms or an ultrasound, you would then want to inject into that joint as well, your own platelets. And then lastly and likely most importantly is that you also want to treat all the ligaments that are leading to that instability as well. Instability is really what this is about and that’s what’s causing the impingement. And so if you have that space where the rotator cuff is running is getting impinged and squeezed down upon, you want to make sure that you appropriately treat all the ligaments that are leading to that instability. And the reason why is because if you do, you’ll give your shoulder a better chance of recovering from that injury. You’ll give your shoulder and rotator cuff a better chance of not getting progressively damaged, and you’ll give your AC joint above your shoulder a better chance of not becoming arthritic as well. So shoulder impingement surgery- no better than just physical therapy or just a diagnostic evaluation. Maximize your nonsurgical alternative options. And if you’ve already done that, then instead of proceeding with a surgery that shaves off the bone, that is no better than just physical therapy, I would recommend proceeding with the regenerative medicine treatment in a proper manner where you’re treating the whole structure, the whole functional unit to get that better. Great. Thank you very much. As a reminder, I’m doing this twice per week, Mondays and Wednesdays. In addition, this Wednesday evening, I’m also doing a webinar on regenerative medicine treatments for lower back issues. And until we talk again, have a good day and live well. Bye bye.

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