Shoulder Still Painful After Subacromial Decompression Surgery

Recently, we had a patient referred to our clinic for his shoulder pain (shoulder impingement). He had pain just lifting his arm/shoulder sideways. After talking to him, he mentioned that he already had surgery a few years ago to remove part of his acromion to increase the subacromial space. 

R shoulder impingement

This surgery (usually called subacromial decompression) is done to free up more space for the supraspinatus muscle and subacromial bursa so there is less chance of an impingement.

If part of the acromion (see picture above) was already shaved off and removed, how can the patient still be getting shoulder pain from shoulder impingement?

Actually, I was not surprised at all. Two recent systematic reviews/ meta-analyses and a Cochrane systematic review (referenced below) concluded with high certainty that for patients who painful shoulder impingement, subacromial decompression surgery does not help. Pain wise, function or health-related quality of life is not better compared with placebo surgery or physiotherapy.

In the United States alone, there are more than 500,000 procedures of subacromial compression done for subacromial pain, or in conjunction with a rotator cuff repair every year. 

In another recently published study, authors from Finland did a 5 year follow up on patients to compare arthroscopic subacromial decompression versus diagnostic arthroscopy, a placebo surgical intervention, and exercise therapy. They found that arthroscopic subacromial decompression provided no benefit over diagnostic arthroscopy or exercise therapy at 5 years follow up.

Looking at all the current evidence, if you have subacromial shoulder pain or shoulder impingement, then it is safe to say that going under the surgeon's knife may not help after all. The study by Paavola et al (2020) suggested exercise therapy was just as effective.

What did we do? Treating his neck and nerve root irritation got rid of his shoulder pain.

References

Hao Q, Devji T, Zeraatkar D et al (2019). Minimal Important Differences For Improvement In Shoulder ConditionPatient-reported Outcomes: A Systematic Review To Inform a BMJ Rapid Recommendation. BMJ Open DOI: 10.1136/bmjopen-2018-028777.

Karjalainen TV, Jain NB, Page CM et al (2019). Subacromial Decompression Surgery For Rotator Cuff Disease. Cochrane Database Syst Rev. 1:CD005619. DOI: 10.1002/14651858.CD005619.pub

Lahdeoja T, Karjalainen TV, Jokihaara J et al (2020). Subacromial Decompression Surgery For Adults With Shoulder Pain: A Systematic Review With Meta-analysis. BJSM. 54: 665-73. DOI: 10.1136/bjsports-2018-10048.

Paavola M, Kanto K, Ranstam J et al (2020). Subacomial Decompression Versus Diagnostic Arthroscopy For Shoulder Impingement: A 5-year Follow-up Of A Randomised, Placebo Surgery Controlled Clinical Trial. BJSM 55(2): 99-107. DOI: 10.1136/bjsports-2020-102216.

Many Physiotherapists Cannot Prescribe Exercise?

Teaching Ronald Susilo how to ride

I definitely don't agree with the following research (Barton et al, 2021) which concluded that physiotherapists cannot prescribe physical activity and exercise well for people with muscle and joint pain/ problems. Let me explain further.

I was asked to go to court last year to be questioned by the lawyer of the insurer (for the truck driver) for my accident in 2013. Yes, after waiting for almost 7 years, and numerous adjournments by the other party, the hearing was finally scheduled. 

Their lawyer questioned why I needed physiotherapy after my accident and he added that "isn't physiotherapy just doing some exercises". If so then I would not need to attend any more sessions and just do the exercises at home and the insurer would not have to pay anymore.

I explained that he (and perhaps the general public) may think when you see a physiotherapist, all the physiotherapist does is to teach you strengthening exercises for your pain or condition. But teaching strengthening exercises isn't the only thing physiotherapists do. At least not at our clinics anyway. 

But physiotherapists in Singapore can definitely teach exercises, especially in the hospital setting. That's what my patients tell me anyway.

Back to the study. 1,352 physiotherapists from 56 countries were surveyed. Most agreed that their job requires exercise prescription of aerobic exercise (75%) and resistance/ strength training (89%) to patients with muscle and joint pain/ problems. 

38 to 50 percent of the physiotherapists reported that they were not confident and had no training/ skills to prescribe aerobic exercise and resistance/ strength training (50 to 67%). Only 11% were able to give the correct guidelines for aerobic exercise and resistance/ strength training (21%).

62 to 79 percent  felt that their packed schedule (seeing too many patients), access to equipment/ space and lack of opportunity to attend professional development affected their ability to prescribe guidelines for effective exercise. 

The authors concluded that many physiotherapists lack training and knowledge to give advice for physical activity, and to prescribe resistance/ strength training and aerobic exercise to people with muscle and joint pain.

The general public (and the lawyer that quizzed me) thinks that all a physiotherapist does is teach exercise for treatment. Is that what you think?

Reference

Barton CJ, King MG, Dascombe G et al (2021). Many Physiotherapists Lack Preparedness To Prescribe Physical Activity and Exercise To People With Musculoskeletal Pain: A Multi-national Survey. Phy Therapy in Sport. DOI: 10.16/j.ptsp.2021.02.002.

Cupping Gone Bad

Picture from Newsflash/ Australscope

Cupping became very popular after Michael Phelps was pictured with cupping marks on his back while competing at the 2016 Rio Olympics.

However, there was a major outcry after a three month old baby with 'too much gas' in Turkey was pictured being treated by cupping. At least cupping seems better compared to a two week old baby being treated by a chiropractor in Melbourne.

In my humble opinion, treatments like that should not be allowed when a child is that young.

Research (a meta-analysis of 135 controlled trials) show that there seems to be no negative effects on adults if cupping was done in moderation (Cao et al, 2012) In addition, adults are able give consent and feedback.

Picture from CEN/ Australscope

Treatment can go wrong with adults too. The 63 year old man pictured above wanted to treat his 'frozen shoulder' and went for cupping treatment 10 days in a row. The person treating him placed the cups in exactly the same positions daily. He was due to continue with the same treatment for two more days but experienced severe pain and a high fever. Fortunately, he went to the hospital instead. 

The following article explains how cupping for treatment works and attempts to offer possible  explanations of its effects (Al-Bedah et al, 2019), of which includes the Pain Gate Theory, TENs, blood detoxification and Reflex zone theory etc. However, no single theory exists to explain the whole effect of cupping.

Well, what we can learn from the above incidences is to ensure that cupping isn't done to the same spot on consecutive days.

References

Al-Bedah AMN, Elsubai IS, Qureshi NA et al (2019). The Medical Perspective Of Cupping Therapy: Effects And Mechanisms Of Action. J Tradit Complement Med. 9(2): 90-97. DOI: 10.1016/j.jcme.2018.03.003

H Cao, X Li and J Liu (2012). An Updated Review Of The Efficacy Of Cupping Therapy. PLos One. 7(2): e31793. DOI: 10.1371/journal.pone.0031793.

Motion Control Shoes To Control Overpronation?

Brooks Adrenaline GTS 21

Most of our patients choose their running shoes based on comfort. Recently, we've had a few new patients who were told to buy motion control shoes to control pronation. Yes, there are still sales people from running shoe shops, doctors, physiotherapists and podiatrists etc who recommend running shoes based on their foot type. 

They will check if you have a normal, high, low/ or no arches and then recommend you use stability, cushion and motion control shoes respectively. The rationale for motion control shoes are that since a person with low or no arches tends to overpronate, they need sturdy motion control shoes to control that overpronation.

What does current research say?

327 runners were studied and followed up for six months by researchers. The runners were randomly allocated to run in neutral running shoes or motion control shoes (Malisoux et al, 2016). The researchers concluded that runners who used motion control shoes will benefit those with low/ no arches (or or pronated feet).

Another group of researchers (Willems et al, 2020) reanalyzed data from Malisoux's 2016 study to include type of injury sustained. Malisoux was also in this current group of researchers. Running injuries that occurred were classified into pronation related (Achilles tendinopathy, plantar fasciitis, exercise related lower leg pain and anterior knee pain) or other running related injuries.

Upon analysis, 25 runners were found to have sustained pronation related injuries while 68 other runners had other running related injuries. Those who ran with a motion control shoe had a lower risk or pronation related injuries while there was no difference on the risk of other running related injuries.

The above mentioned results differs from previous published research on motion control shoes which showed that runners who overpronated and assigned to run in motion control shoes actually complained of pain and missed training days after wearing them (Ryan et al 2011). Another published study involving 927 new runners also found that pronation is not associated with increased injury risk.

The contrast in conclusions will no doubt confuse you. I was initially confused too. It is always difficult to combine multiple sources and research methods to come away with practical results because the definitions vary.

The main question for me in the Willems et al (2020) study is how do they really know any of the running injuries are 'pronation related'? They also defined injury as pain interfering with training for 1 day. Other studies defined injury as no running for a week.

My suggestion is to assess individual response to change in footwear and see if it reduces pain/ injury. If it does, then you should lay off that pair of running shoes for a while before trying it again. 

References

Nielsen RO, Buist I, Parner ET et al (2014). Foot Pronation Is Not Associated With Increased Injury Risk In Novice Runners Wearing A Neutral Shoe: A 1-year Prospective Cohort Study. BJSM. 48: 440-447. DOI: 10.1136/bjsports-2013-092202

Malisoux L Chambon N, Delattre N (2016). Injury Risk In Runners Using Standard Or Motion Control Shoes: A randomised Controlled Trial With Participant And Assessor Blinding. BJSM. 50(8): 481-487. DOI: 10.1136/bjsports-2015-095031

Ryan MB, Valiant GA, McDonald K et al (2011). The Effect Of Footwear Stability Levels On Pain Outcomes In Women Runners: A Randomised Control Trial. BJSM. 45:715-721. DOI:10.1136/bjsm.2009.069849 

Willems T, Ley C, Goetghebeur E et al (2020). Motion Control Shoes Reduce The Risk Of Pronation-related Pathologies In Recreational Runners: A Secondary Analysis Of A Randomized Controlled Trial. JOSPT. pp 1-31. DOI: 10.25

rent Malisoux,

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Nicolas Chambon,

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Nicolas Delattre,

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Nils Guegu