Subacromial pain. What?!

14th Nov, 2022

Key Points

  1. Understanding subacromial pain: Subacromial pain is a common shoulder issue, often managed with surgery or physiotherapy.
  2. Study findings: Recent studies question the efficacy of subacromial decompression surgery compared to non-operative treatments.
  3. Management of subacromial pain: Traditional management includes rest, medications, and sometimes surgery, but new evidence supports physiotherapy as effective.
  4. Patient considerations: Patients should consider non-operative treatments first, with surgery as a last resort.
  5. Clinical implications: Physiotherapists should integrate new research findings into practice, emphasising non-surgical treatments.

What is subacromial pain?

Subacromial pain, often referred to as shoulder impingement, occurs when the rotator cuff tendons are compressed as they pass through the subacromial space, leading to pain and inflammation. This condition is common and can significantly impact daily activities and quality of life.

What was done in the study?

The study titled “Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW)” aimed to assess the effectiveness of subacromial decompression surgery. The study was a multicentre, randomised, placebo-controlled trial involving 313 patients with subacromial pain. Participants were divided into three groups:

  1. Decompression surgery: Involving removal of bone spurs and soft tissue to enlarge the subacromial space.
  2. Arthroscopy only: A placebo surgery where no decompression was performed.
  3. No treatment: Participants attended one reassessment appointment but received no intervention​​.

What they found in all 3 groups of the study

The findings from the study were insightful and challenged traditional perspectives on managing subacromial pain. Here’s a summary of what was discovered across the three groups:

  1. Decompression Surgery Group:
    • Patients in this group underwent the standard decompression surgery where bone spurs and soft tissue were removed to increase the space around the rotator cuff tendons.
    • Results showed improvement in pain and shoulder function post-surgery. However, the improvement was not significantly different from the placebo group.
  2. Arthroscopy Only Group:
    • This group had a placebo surgery where the arthroscopy was performed but no decompression was done. The aim was to see if the surgical process itself had a therapeutic effect.
    • Interestingly, patients in this group also reported improvements in pain and function. The results were comparable to those in the decompression group, suggesting that the act of surgery might have a placebo effect.
  3. No Treatment Group:
    • Participants in this group did not receive any surgical intervention. They were reassessed after a period to determine if natural healing or conservative management led to improvement.
    • The findings revealed that many patients in this group also showed improvement in pain and function over time, similar to the surgical groups.

The overall conclusion of the study was that there was no significant difference in outcomes between those who had decompression surgery and those who underwent placebo surgery or no surgery at all. This suggests that non-operative treatments and time may be just as effective as surgical interventions for managing subacromial pain​​.

Usual way in the management of subacromial pain

Traditionally, subacromial pain is managed through a combination of:

  • Rest and activity modification: Reducing activities that exacerbate pain.
  • Medications: Using NSAIDs and corticosteroid injections to reduce pain and inflammation.
  • Physical therapy: Implementing exercises to strengthen shoulder muscles and improve flexibility.
  • Surgery: In cases where conservative treatments fail, subacromial decompression surgery is considered. This procedure involves removing bone spurs and soft tissue to relieve pressure on the rotator cuff tendons​​.

If you are experiencing subacromial pain, consider the following management steps:

  1. Start with conservative treatments: Engage in a structured physiotherapy programme focusing on exercises to improve shoulder strength and flexibility.
  2. Use medications wisely: Use NSAIDs for pain relief as needed, but avoid over-reliance on medications.
  3. Avoid immediate surgery: Reserve surgery as a last resort after exploring all non-operative options.
  4. Seek regular assessments: Regularly consult with your physiotherapist or doctor to monitor your progress and adjust your treatment plan as needed​​.

As a Physiotherapist, managing patients with shoulder pain, you should:

  1. Emphasise non-operative treatments: Prioritise exercise and manual therapy over surgical options.
  2. Educate patients: Inform patients about the nature of their condition and the benefits of physiotherapy.
  3. Monitor patient progress: Regularly assess pain and function to adjust treatment plans as needed.
  4. Stay informed: Keep up-to-date with the latest research to provide the best care possible​​.

Conclusion

Subacromial pain is a common shoulder issue that can significantly impact daily activities. Traditional management includes rest, medications, and sometimes surgery, but recent studies highlight the effectiveness of physiotherapy and question the necessity of subacromial decompression surgery. Patients should consider non-operative treatments first, and physiotherapists should integrate new research findings into their practice to improve patient outcomes.

Ref:

Beard, D. J., Rees, J. L., Cook, J. A., Rombach, I., Cooper, C., Merritt, N., Shirkey, B. A., Donovan, J. L., Gwilym, S., Savulescu, J., Moser, J., Gray, A., Jepson, M., Tracey, I., Judge, A., Wartolowska, K., & Carr, A. J. (2018). Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW): a multicentre, pragmatic, parallel group, placebo-controlled, three-group, randomised surgical trial. The Lancet, 391(10118), 329-338. https://doi.org/10.1016/S0140-6736(17)32457-1

Frequently Asked Questions

What is subacromial decompression surgery?

Subacromial decompression surgery involves removing bone spurs and soft tissue to enlarge the subacromial space and relieve pressure on the rotator cuff tendons. However, recent studies question its efficacy compared to non-operative treatments​​.

How effective is Physiotherapy for subacromial pain?

Physiotherapy, including exercises and manual therapy, is highly effective in managing subacromial pain. It helps improve shoulder strength, flexibility, and function​​.

When should surgery be considered for subacromial pain?

Surgery should be considered only after exhausting all non-operative treatments, such as Physiotherapy and medications. Recent evidence suggests that surgery may not provide significant additional benefits over conservative treatments​​.

What are the risks of subacromial decompression surgery?

Risks of subacromial decompression surgery include infection, nerve damage, and frozen shoulder. Moreover, the benefits of the surgery may not outweigh these risks, as recent studies indicate limited efficacy​​.

How long does recovery take after subacromial decompression surgery?

Recovery after subacromial decompression surgery can take several months. Patients typically undergo physiotherapy post-surgery to regain shoulder function and strength. However, non-operative treatments can often achieve similar results without the risks associated with surgery​​.

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