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Jeremy Lewis, a Consultant Physio, Sonographer and Professor in the UK, recently presented a course in Melbourne on Shoulders. Annie and Emma from the Pure team attended to learn about recent findings in research of surgery versus conservative management of shoulder pain.
The evidence is leaning more and more towards physiotherapy exercise being the treatment of choice for “Subacromial Impingement syndrome”. That’s why we at Pure put so much emphasis on the rehabilitation aspect of Physiotherapy treatment – it’s being proven more and more that it’s a cost effective, low risk option for management of shoulder pain.
As Cara discussed a few months ago (link to March post), it can sometimes be hard to decide if surgery is the right way to manage your shoulder pain – you need to consider the cause of pain (traumatic fall or gradual onset), individual risk factors associated with surgery, goals for return to activity post-operatively and overall financial costs/time off work. Lewis’ course went into detail about whether people with shoulder pain are in need of surgery in the first place and then the pro’s and con’s of surgery vs physiotherapy exercise to manage symptoms.
Lewis went back to the beginning and discussed the diagnosis of shoulder pain – mainly related to conditions known as Subacromial Impingement Syndrome and Rotator Cuff injury. Often people with shoulder pain will be sent to have some sort of imaging to help to diagnose their condition – it might be x-ray, ultrasound scan or an MRI. It has been found, however, that a lot of people who don’t actually have any shoulder pain, will have structural abnormalities in their shoulders. One in five people in the general population have a rotator cuff tear shown on scans with only a third of these people having symptoms. So can we be sure that a tear or other abnormality that shows up on a scan, really relates to a persons’ shoulder pain?
One study found that on x-ray and ultrasound, tears were more likely to be asymptomatic/not painful. Another study also discovered that on ultrasound scan, structural shoulder abnormalities were present in 96% of people who didn’t even have any shoulder pain. There was also evidence from another study using MRI on baseball pitchers and tennis players that found that 90% of the athletes had some sort of structural abnormality, yet no shoulder pain. There is so much evidence out there that shows that the presence of a rotator cuff tear or other subacromial abnormality does not directly correlate with painful shoulder dysfunction.
The next thing to consider is if surgery is the best option to actually change your symptoms and take away your shoulder pain. One surgical option is Acromioplasty, where the surgeon removes part of the acromion (the arch of bone that sits at the top of the ball and socket joint). A recent study last year stated that “…acromioplasty is not superior to exercise in the treatment of rotator cuff tendinopathy” and even suggested that the benefit of some orthopaedic procedures are placebo. Surgery was more expensive and associated with more time off work, whereas physiotherapy exercise cost less, had more generalised benefits and lower risk of adverse events.
Another common surgical procedure is Subacromial Decompression (SAD). One research article showed that there were no significant differences in outcomes between groups who had had SAD versus those who only had physiotherapy exercise – except that the surgery cost 2-3x more than the physiotherapy.
So the answer seems to be follow the research – physiotherapy is the way forward!!