Purpose
To construct an algorithm to optimize clinical outcomes in subacromial impingement
based on current, high-level evidence.
Methods
A systematic review of all clinical trials on subacromial impingement published from
1999 to 2020 was performed. Demographic, clinical, range of motion (ROM), and patient-reported
outcome measure (PROM) data were collected. Interventions were compared via arm-based
Bayesian network meta-analysis in a random-effects model and treatments ranked via
surface under the cumulative ranking curves with respect to 3 domains: pain, PROMs,
and ROM.
Results
A total of 35 studies comprising 3,643 shoulders (42% female, age 50 ± 5 years) were
included. Arthroscopic decompression with acromioplasty ranked much greater than arthroscopic
decompression alone for pain relief and PROM improvement, but the difference in absolute
PROMs was not statistically significant. Corticosteroid injection (CSI) alone demonstrated
inferior outcomes across all 3 domains (pain, PROMs, and ROM) with low cumulative
rankings. Physical therapy (PT) with CSI demonstrated moderate-to-excellent clinical
improvement across all 3 domains whereas PT alone demonstrated excellent ROM and low-moderate
outcomes in pain and PROM domains. PT with nonsteroidal anti-inflammatory drugs or
alternative therapies ranked highly for PROM outcomes and moderate for pain and ROM
domains. Finally, platelet-rich plasma injections demonstrated moderate outcomes for
pain, forward flexion, and abduction with very low-ranking outcomes for PROMs and
external rotation.
Conclusions
Arthroscopic decompression with acromioplasty and PT demonstrated superior outcomes
whereas CSI demonstrated poor outcomes in all 3 domains (pain, PROMs, and ROM). For
patients with significant symptoms, the authors recommend PT with CSI as a first-line
treatment, followed by acromioplasty and PT if conservative treatment fails. For patients
with symptoms limited to 1 to 2 domains, the authors recommend a shared decision-making
approach focusing on treatment rankings within domains pertinent to individual patient
symptomatology.
Level of Evidence
I, systematic review and network meta-analysis of Level I studies.
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Article info
Publication history
Published online: February 18, 2022
Accepted:
February 4,
2022
Received:
August 16,
2021
Footnotes
See commentary on page 2525
The authors report the following potential conflicts of interest or sources of funding: B.F. reports grants from Arthrex, personal fees from Elsevier, other from Jace Medical, grants from Smith & Nephew, and personal fees from Stryker, outside the submitted work. Full ICMJE author disclosure forms are available for this article online, as supplementary material.
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© 2022 Published by Elsevier on behalf of the Arthroscopy Association of North America
