Shoulder and Elbow
I read with interest a recent paper: “No evidence of long-term benefits of arthroscopic acromioplasty in the treatment of shoulder impingement syndrome”.1 The title caught my eye as, if correct, the findings of this study could have significant impact on the way we treat patients with shoulder impingement.
While the title of this paper achieved the goal of drawing in the reader in my case, and would probably have similar effects on the media and commissioners, the devil of the paper is in the detail.
I have had to read this paper several times to determine if it does what it says on the tin. One of the biggest issues identified is with its inclusion criteria. The inclusion criteria include “attempts to treat with: rest, NSAIDS, subacromial corticosteroid injections and regular physiotherapy” however there is no clear statement that all patients had corticosteroid injections. The authors do state that all patients had physiotherapy but that this included “massage, heat, transcutaneous nerve stimulation and exercise.” The study included patients from 18 to 60 years old and in fact the youngest patient was just 23 years old. ...
Diagnosis of shoulder impingement was made by a positive Neer’s test (subacromial lidocaine injection), however, all patients had radiographs and MRI scans but no comment was made as to whether the MRI scans demonstrated features consistent with impingement.
Patients were randomised into two groups: physiotherapy, and “combined treatment” i.e. surgery followed by physiotherapy. The outcome measures include a visual analogue scale for pain as the primary outcome measure, and shoulder disability questionnaire, but no common shoulder scores such as DASH, SPADI, or OSS.
While the groups were randomised there is no description of the demographics of each group and interestingly despite being diagnosed with shoulder impingement 11 of 140 patients were described as pain free at initial assessment. Of the patients randomised to physiotherapy, 25% (18 of 70) eventually had surgery before final assessment. It was also noted that 17% of patients (12 of 70) randomised to surgery refused an operation. Although patients were seen at three months, six months, two years, and five years, only the 2-year and 5-year results were provided so no determination could be made as to whether the groups behave differently in the early course of follow-up.
The most telling statement in this paper is in the discussion: “In these earlier studies, failure to respond to regular physiotherapy and other conservative treatment was used as an inclusion criterion. In contrast, the present study aimed to examine whether operative treatment provided any additional value to a conservative structured exercise treatment.”
The crux of the matter is that for most in the UK the indication for surgery in shoulder impingement is failed conservative management which includes corticosteroid injection AND shoulder physiotherapy. By UK standards therefore this study probably over-treated many patients who would have otherwise improved with physiotherapy alone. Indeed in the physiotherapy group only 25% went on to have surgery. The 17% who refused surgery probably didn’t think their symptoms were significant enough to warrant it.
Thus the conclusion that arthroscopic acromioplasty is of no benefit is wrong in my opinion. What this study shows however is that patients should have failed physiotherapy before being considered for surgery as most seem to do well with physiotherapy alone. Thankfully this is already what most of us already do in practice.
Mr Nicholas A. Ferran, Specialist Registrar, University Hospitals of Leicester NHS Trust, Leicester, UK
1. Ketola S, Lehtinen J, Rousi T, et al. No evidence of long-term benefits of arthroscopicacromioplasty in the treatment of shoulder impingement syndrome: Five-year results of a randomised controlled trial. Bone Joint Res 2013;2:132–9.