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Should I have shoulder surgery? What does the evidence say?

Got Shoulder Pain?

Having shoulder pain feels rubbish.  We use our arms a lot so that means your shoulder can can hurt, a lot! A common diagnosis you might be given is one of ‘impingement’ or ‘rotator cuff tear’.  Impingement relates to pain believed to be coming from one of the structures above the ‘ball’ and under the top of the ‘socket’. Either from tendons (how a muscle attached to the bone) or from the bursa (a fluid filled sac between a tendon and a bone).  Rotator cuff tears we will come on to later.  Typically you may feel pain in the upper arm, or near to the shoulder with both diagnoses.

‘Impingement’ – you’ll find out later why we keep putting it in those inverted commas.

You may have had an

  • ultrasound scan at which you were told ‘yes, you have impingement’
  • x-ray and been told that you have a bone that needs scraping away.
  • MRI scan showing a rotator cuff tendon tear

You may have also been told that the scan shows that a bone is rubbing against the tendon.

Sometimes this leads to you being offered surgery.  Now that is pretty drastic so let’s look at the evidence behind firstly one type of surgery known as sub acromial decompression .

Sub Acromial Decompression Surgery

A study called the CSAW trial was published in November 2017.  In the trial they did something very interesting.  They compared 3 groups of people who had been suffering with  shoulder pain for more than 3 months. These people had tried a steroid injection and had no full rotator cuff muscle/tendon tears.  They randomly put people into one of the following 3 groups .

  • Group 1  – sub acromial decompression surgery
  • Group 2 – investigational arthroscopy (keyhole) surgery only
  • Group 3 – no treatment/no surgery/no rehab

So here’s the interesting part.  They found no difference in the improvement between the group who had ‘real’ surgery (Group 1) and the group who had ‘fake’ surgery (Group 2).  But these 2 groups did improve more than the no treatment group.  The authors thought that the difference between the surgical groups and the no treatment group might be the result of,  a placebo effect OR postoperative physiotherapy. So….one conclusion is why would you have the ‘real’ surgery?

It should be now widely accepted that so called ‘impingement’ type pain IS NOT caused by the bone rubbing on the tendon and wearing it out.  Therefore why are bits of bone still being shaved off?! Good question!

Rotator Cuff Tears

This type of pain is similar if not the same type of shoulder pain that historically has been called impingement.  The type of results mentioned above tie in with another group of trials that compared surgery versus physiotherapy rehabilitation for rotator cuff tears.  A systematic review (a research paper that tries to  draw together all the evidence around a topic) published in 2017 on Surgery versus No Surgery for full thickness rotator cuff tears concluded

‘the differences in pain scores were small and did not meet the minimal difference considered clinically significant’.

So the outcomes were basically very similar whether you had an operation or just had active physical rehabilitation.

The results of other trials also show at 2,3 and 5 years after intervention (operation OR rehab) that surgery is no better than active physical rehabilitation. There is strong evidence that rehabilitation of the surrounding muscles in the shoulder and upper back around the shoulder blade is equal to surgical repair but without all the risks and costs.  So again….why go under the knife?!

Now you might be saying to yourself, “well i have a rotator cuff tear”.  Well another study, in 2017, (must have been the year to study shoulders!) looked at the effectiveness of rotator cuff repair surgery and concluded; ‘The rate of re-tear is high, for all sizes of tear and ages and this adversely affects the outcome’.  So even if they do repair it, there is a high chance that it will re-tear.

Research has changed what we think (or should!)

I am sure you will agree that things in life take a while to change, regardless of how strong the argument for change is.  Well this is just the same. Things are changing, for the better, just very slowly.

Here’s are some important things to remember from MRI and ultra sounds scan studies:

  • The prevalence of rotator cuff tears in the general population is common and increases with age. Asymptomatic tears (no pain or symptoms) were seen twice as commonly as a symptomatic tear (a painful shoulder).
  • It is normal to have a rotator cuff tendon tear without pain or loss of function as you get older.

Now acute tendon tears in individuals in their 20′ and 30’s are a different kettle of fish. It often follows a distinct injury and they have a sudden loss of power. But that is not the typical person with shoulder pain.

If you do have shoulder pain the problem is most often functional or postural and can be resolved with active physical rehabilitation.  It just takes a bit of commitment to do some exercise based rehabilitation.

So what are we ultimately saying?

Well we are not saying that nobody should have any shoulder operation.  What we are saying is that we want you to know all the facts before making any decision on a shoulder operation.  As you can see, things are complicated and surgery is not always the answer.  We are also saying that by trying active physical rehabilitation you will lose nothing, in fact , you will likely get better!

Just remember though,

‘electric machines are a waste of time for this type of problem’

‘rubbish efforts and rubbish rehab give rubbish outcomes. Great efforts and great rehab give great outcomes.’

If you have shoulder pain and would like to find out how to get better without the need for injections, pills or surgery please get in touch.

Please share this using the links below with anyone you know struggling with shoulder pain or a rotator cuff tear or anyone considering shoulder surgery for ‘impingement’.