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.

Shoulder Pain From Swimming? Treat Your Neck

Yes, your shoulder pain is coming from your neck

I had a really interesting case this past week. A patient who's an elite swimmer comes in to our clinic complaining of shoulder pain.

An ultra sound scan and MRI that was done confirms the diagnosis of shoulder subacromial impingement (usually the tendon of the supraspinatus muscle gets irritated from hand above head activities under the acromium).

The doctor my patient saw the the Singapore Sports Institute suggested a steroid (or cortisone) injection to "solve the problem".

R shoulder impingement

Well, the Physiotherapists reading this must be thinking "yeah, what's the big deal". All elite swimmers (or athletes involved with overhead sports like badminton, tennis etc) always get shoulder pain from subacromial impingement at some point of other in their sporting career.

Well, here's the thing, I got the swimmer better just be treating the swimmer's neck. This swimmer did not have any neck pain or signs of nerve root irritation.

I've seen other cases of shoulder impingement when the patient had obvious clues suggesting it was the neck and/ or nerve root irritation causing the shoulder impingement.

This swimmer did not have any neck pain or nerve root irritation signs. The patient did have a forward head posture which can contribute to a C5 nerve root involvement.

Similar to the article referenced below, the swimmer got better very quickly just by cervical retraction, as taught by Gwen Jull. Of course treatment also included other things and not just cervical retraction.

My swimmer went back to full training in three days with no recurrence of symptoms. Good thing my patient said no to the steroid or cortisone injection.

Reference

Pheasant S (2016). Cervical Contribution To Functional Shoulder Impingement: Two Case Reports. Int J Sports Phys Ther. 1196): 980-991.