Shoulder surgery, a waste of time?

Pain in the shoulder is a common concern amongst workers. When the pain persists or increases to the point it begins to affect work and other areas of life, a worker may turn to surgery. Is this the right choice?

Sub-acromial pain syndrome (SAPS) is a general term for any non-traumatic shoulder pain associated with structures within the subacromial space (where the shoulder and arm meet). This pain can be at the front, back or side of the shoulder and worsens when lifting the arm. SAPS is one of the most common shoulder disorders, accounting for up to 65% of all shoulder pain.

Many people with SAPS will receive subacromial decompression surgery, with 21,000 surgeries done in the United Kingdom during 2018 and twice as many done in the United States of America. In a recent clinical practice guideline, authors strongly recommended against subacromial decompression surgery for patients with SAPS. The guideline states there is no advantage of decompression surgery for the outcomes of pain, function, quality of life, global perceived effect, and return to work when compared to exercise.

Supervised non-operative rehabilitation is backed by Level 4 (strong) evidence to decrease shoulder pain and increase function. Similarly, strength and mobility exercises for the shoulder can be effective in reducing pain and improving function in SAP.

Subacromial decompression surgery can have a high impact on workplace lost time injury (LTI) numbers and loss in productivity. Studies found that after this surgery, most non-manual workers and drivers required six weeks of absence, whilst manual workers were more likely to be absent for approximately 3 months. Typically, this return to work would only begin as modified duties.

Due to the evidence for exercise and the potential risks involved with surgery, as well as the potential of months of time off work needed to recover, workers should consult with their health professional on conservative, non-operative measures initially.

It’s now well accepted the less time absent from work correlates with better physical and mental outcomes for workers. Ideally, being proactive and avoiding this scenario by having workers physically and mentally beyond their job requirements is what the goal should be.

Workers and workplaces need to get a better understanding of whether shoulder surgery is indicated. Most often, surgery is not indicated in some of the most common shoulder complaints such as SAPS. An onsite physiotherapy presence, such as an Employ Health – Health Hub, is perfectly positioned to assess and provide evidence-based conservative care, proactive approaches, or to refer onward if necessary.

References

1. Appraisal of Clinical Practice Guideline: Subacromial decompression surgery for adults with shoulder pain: a clinical practice guideline, Journal of Physiotherapy, Volume 65, Issue 3,2019,ISSN 1836-9553, https://doi.org/10.1016/j.jphys.2019.05.002.
2. Bhattacharyya R, Edwards K, Wallace AW. Does arthroscopic sub-acromial decompression really work for sub-acromial impingement syndrome: a cohort study. BMC Musculoskelet Disord. 2014;15:1. 
3. Charalambous CP, Sahu A, Alvi F, Batra S, Gullett TK, Ravenscroft M. Return to work and driving following arthroscopic subacromial decompression and acromio-clavicular joint excision. Shoulder Elbow. 2010;2:83-86. http:// dx.doi.org/10.1111/j.1758-5740.2010.00048.x
4. Lähdeoja T : Subacromial decompression surgery for adults with shoulder pain: A systematic review with meta-analysis (in submission). In submission BMJ 2018;
5. Lähdeoja T, Karjalainen T, Jokihaara J et al : Subacromial decompression surgery for adults with shoulder pain: a systematic review with meta-analysis.. British journal of sports medicine 2019; PubmedJournal
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1. Mika Paavola, Antti Malmivaara, Simo Taimela, Kari Kanto, Jari Inkinen, Juha Kalske, Ilkka Sinisaari, Vesa Savolainen, Jonas Ranstam, Teppo L N Järvinen. Subacromial decompression versus diagnostic arthroscopy for shoulder impingement: randomised, placebo surgery controlled clinical trial. BMJ, 2018; k2860 DOI: 10.1136/bmj.k2860

8. Smith M, Sparkes V, Busse M, Enright S. Upper and Lower trapezius muscle activity in subjects with subacromial impingement symptoms: Is there imbalance and can taping change it? Physical Therapy in Sport. 2009:10, 45-50 (Level of evidence 3b)
9. Stefanos Farfaras, Ninni Sernert, Lars Rostgard Christensen; Subacromial Decompression Yields a Better Clinical Outcome Than Therapy Alone: A Prospective Randomized Study of Patients With a Minimum 10-Year Follow-up; First Published March 15, 2018; The American Journal of Sports and Medicine
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11. Theresa Holmgren, Hanna Björnsson Hallgren, Birgitta Öberg, Lars Adolfsson, Kajsa Johansson; Effect of specific exercise strategy on need for surgery in patients with subacromial impingement syndrome: randomised controlled study; BMJ 2012; 344 (Published 20 February 2012)