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Surgery not the answer for subacromial pain syndrome

By Nicole Mackee
Decompression surgery should no longer be offered to patients with subacromial pain syndrome (SAPS), international experts write in the BMJ.

Two recent trials (BMJ 2018; 362: k2860 and Lancet 2018; 391: 329-338) found that subacromial decompression surgery provided no benefit over placebo surgery in the management of patients with SAPS. This lead to the formation of a multidisciplinary panel of experts – including clinicians and patients with a lived experience of shoulder pain and surgery – to evaluate the latest evidence for the use of subacromial decompression surgery.

The panel instigated two linked systematic reviews and used the GRADE approach to assess the quality of evidence. The resulting clinical practice guideline concluded that surgery did not provide improvements in pain, function and quality of life compared with placebo surgery or other therapies. They added that surgery may be associated with harms, such as frozen shoulder.

Professor Michael Shanahan, Head of Rheumatology, Southern Area Local Health Network and Professor of Musculoskeletal Medicine at Flinders University, Adelaide, said the guideline was based on good-quality data that needed to be considered when making the decision to either operate or to find an alternative management strategy.

‘Although I would not go so far as to say that no patient should be offered subacromial decompression, we now have good-quality research which suggests that, for most patients, this particular procedure is unlikely to be of significant benefit for their shoulder pain,’ Professor Shanahan said. Much work is needed to better understand chronic shoulder pain and how best to manage it, he added.

‘We remain very focused on the notion that “abnormalities” seen on imaging of the shoulder explain an individual’s pain and, by extension, correcting these abnormalities is likely to fix the problem,’ Professor Shanahan said. ‘There is ample evidence that many of the changes seen on imaging do not in fact explain the presentation of chronic shoulder pain and therefore surgically intervening in an attempt to correct them – for example, “decompressing an impinging tendon” – is likely to be ineffective.’

Professor Shanahan said a further challenge was educating patients with chronic shoulder pain, as well as those who refer patients for intervention, that surgery may not be the answer.

‘A very natural and understandable response from the patients is then, “what is the best approach to manage my pain?” This is where we need to focus more research energy, as many of the currently available treatments are of limited utility, and when people suffer pain there is great pressure to try to relieve this as quickly and effectively as possible.’
BMJ 2019; 364: l294.