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Editorial Commentary: Arthroscopic Treatment Should No Longer Be Offered to People With Subacromial Impingement

      Abstract

      Arthroscopic treatment should no longer be offered to people with subacromial impingement. In many people, subacromial impingement (or subacromial pain syndrome) is self-limiting and may not require any specific treatment. This is evident by the fact that almost 50% of people with new-onset shoulder pain consult their primary care doctor only once. The best-available evidence from randomized controlled trials indicates that glucocorticoid injection provides rapid, modest, short-term pain relief. Exercise therapy has also been found to provide no added benefit over glucocorticoid injection. Subacromial decompression (bursectomy and acromioplasty) for subacromial pain syndrome provides no important benefit on pain, function, or health-related quality of life. Acromioplasty does not improve the outcomes of rotator cuff repair.
      In many people, subacromial impingement (or subacromial pain syndrome) is self-limiting and may not require any specific treatment beyond reassurance about its favorable prognosis and self-management advice. This is evident by the fact that almost 50% of people with new-onset shoulder pain consult their primary care doctor only once, and for the majority care comprises a wait-and-see policy or a nonsteroidal anti-inflammatory prescription.
      • Dorrestijn O.
      • Greving K.
      • van der Vee W.J.
      • et al.
      Patients with shoulder complaints in general practice: Consumption of medical care.
      The best-available evidence from randomized controlled trials indicates that glucocorticoid injection provides rapid, modest, short-term pain relief,
      • Cook T.
      • Minns Lowe C.
      • Maybury M.
      • Lewis J.S.
      Are corticosteroid injections more beneficial than anaesthetic injections alone in the management of rotator cuff-related shoulder pain? A systematic review.
      a highly appreciated benefit to patients when their pain is at its worst.
      • Page M.J.
      • O’Connor D.A.
      • Malek M.
      • et al.
      Patients’ experience of shoulder disorders: A systematic review of qualitative studies.
      Despite hundreds of trials, the efficacy of exercise therapies and its optimum components is still highly uncertain.
      • Page M.J.
      • Green S.
      • McBain B.
      • et al.
      Manual therapy and exercise for rotator cuff disease.
      Most recent trials have found that progressive exercise programs are not superior to a single consultation that provides best practice advice and instruction in self-guided home exercise alone,
      • Granviken F.
      • Vasseljen O.
      Home exercises and supervised exercises are similarly effective for people with subacromial impingement: a randomised trial.
      • Littlewood C.
      • Bateman M.
      • Brown K.
      • et al.
      A self-managed single exercise programme versus usual physiotherapy treatment for rotator cuff tendinopathy: A randomised controlled trial (the SELF study).
      • Hopewell S.
      • Keene D.K.
      • Marian I.R.
      • et al.
      Progressive exercise compared with best practice advice, with or without corticosteroid injection, for the treatment of patients with rotator cuff disorders (GRASP): A multicentre, pragmatic, 2x2 factorial, randomised controlled trial.
      whereas an additional trial found benefits at 6 months but not obvious at 6 weeks or a year.
      • Roddy E.
      • Ogollah R.O.
      • Oppong R.
      • et al.
      Optimising outcomes of exercise and corticosteroid injection in patients with subacromial pain (impingement) syndrome: A factorial randomised trial.
      Exercise therapy has also been found to provide no added benefit over glucocorticoid injection alone.
      • Ellegaard K.
      • Christensen R.
      • Rosager S.
      • et al.
      Exercise therapy after ultrasound-guided corticosteroid injections in patients with subacromial pain syndrome: A randomized controlled trial.
      A 2019 BMJ clinical practice guideline made a strong recommendation against subacromial decompression (bursectomy and acromioplasty) for subacromial pain syndrome based upon high-certainty evidence that it provides no important benefit on pain, function, or health-related quality of life over either placebo (2 trials, up to 285 participants), as well as low-certainty evidence of no important benefits for these outcomes over exercise therapy.
      • Vandvik P.O.
      • Lähdeoja T.
      • Ardern C.
      • et al.
      Subacromial decompression surgery for adults with shoulder pain: A clinical practice guideline.
      Significantly, the panel, which included patients as well as shoulder surgeons, concluded that almost all well-informed patients would decline surgery. There is also moderate-certainty evidence based on 5 trials that acromioplasty does not improve the outcomes of rotator cuff repair.
      • Karjalainen T.V.
      • Jain N.B.
      • Heikkinen H.
      • Johnston R.V.
      • Page C.M.
      • Buchbinder R.
      Surgery for rotator cuff tears.
      Taken together, these data appear to disprove the mechanistic theoretical framework that postulates that rotator cuff tendons degenerate due to impingement and that this process can be halted by making more room for the tendons.
      • Neer C.S.
      Impingement lesions.
      In their article, “Physical Therapy Combined With Subacromial Cortisone Injection Is a First-Line Treatment Whereas Acromioplasty With Physical Therapy Is Best if Nonoperative Interventions Fail for the Management of Subacromial Impingement: A Systematic Review and Network Meta-analysis,”
      • Lavoie-Gagne O.Z.
      • Farah G.
      • Lu Y.
      • Mehta N.
      • Parvaresh K.C.
      • Forsythe B.
      Physical therapy combined with subacromial cortisone injection is a first-line treatment whereas acromioplasty with physical therapy is best if nonoperative interventions fail for the management of subacromial impingement: A systematic review and network meta-analysis.
      Lavoie-Gagne, Farah, Lu, Mehta, Parvaresh, and Forsythe report results that are at odds with what is already known on this topic. While we applaud their efforts, there are numerous reporting and methodologic limitations that mean it is not possible to verify the validity of their findings. One trial, included in a Cochrane review of subacromial decompression, was missing from the current review,
      • Haahr J.P.
      • Ostergaard S.
      • Dalsgaard J.
      • et al.
      Exercises versus arthroscopic decompression in patients with subacromial impingement: A randomised, controlled study in 90 cases with a one year follow up.
      whereas a further 2 studies were excluded due an unexplained limitation placed upon inclusion by year of publication,
      • Peters G.
      • Kohn D.
      Medium-term clinical results after operative and non-operative treatment of subacromial impingement.
      ,
      • Rahme H.
      • Solem-Bertoft E.
      • Westerberg C.E.
      • Lundberg E.
      • Sörensen S.
      • Hilding S.
      The subacromial impingement syndrome. A study of results of treatment with special emphasis on predictive factors and pain-generating mechanisms.
      and/or not being published in the English language.
      • Peters G.
      • Kohn D.
      Medium-term clinical results after operative and non-operative treatment of subacromial impingement.
      A 2020 trial that fulfills inclusion criteria and, which tested the precise algorithm that Lavoie-Gagne et al. are suggesting we should follow was also omitted. Cederqvist et al.
      • Cederqvist S.
      • Flinkkil T.
      • Sormaala M.
      • et al.
      Non-surgical and surgical treatments for rotator cuff disease: A pragmatic randomised clinical trial with 2-year follow-up after initial rehabilitation.
      treated all potential participants with 3 months of physical therapy and only those who didn’t improve were randomized. Even in this select population, there was no identified benefit of subacromial decompression over nonsurgical treatment.
      Transparent details about the trials including their design (e.g., randomized, quasi-randomized); number, size, and description of each treatment arm; period of follow-up and time points included in the analysis; judgments about potential risk of bias and their rationale; and outcome data by trial were also not reported. For example, it is unclear how many included trials were truly randomized; at least one study assigned participants according to their treatment preferences.
      • Aydin A.
      • Yildiz V.
      • Topal M.
      • Tuncer K.
      • Köse M.
      • Şenocak E.
      Effects of conservative therapy applied before arthroscopic subacromial decompression on the clinical outcome in patients with stage 2 shoulder impingement syndrome.
      Categories of risk of bias also were not concordant with the Cochrane tool.
      Most importantly, however, many included studies did not seem to provide relevant data for this review. For example, one trial assessed the value of physical therapy for people who had difficulty returning to usual activities after decompression,
      • Christiansen D.H.
      • Frost P.
      • Falla D.
      • et al.
      Effectiveness of standardized physical therapy exercises for patients with difficulty returning to usual activities after decompression surgery for subacromial impingement syndrome: randomized controlled trial.
      7 compared one form of exercise therapy with another,
      • Björnsson Hallgren H.C.
      • Adolfsson L.E.
      • Johansson K.
      • Öberg B.
      • Peterson A.
      • Holmgren T.M.
      Specific exercises for subacromial pain.
      • Celik D.
      • Akyuz G.
      • Yeldan I.
      Comparison of the effects of two different exercise programs on pain in subacromial impingement syndrome.
      • Dilek B.
      • Gulbahar S.
      • Gundogdu M.
      • et al.
      Efficacy of proprioceptive exercises in patients with subacromial impingement syndrome: A single-blinded randomized controlled study.
      • Maenhout A.G.
      • Mahieu N.N.
      • De Muynck M.
      • De Wilde L.F.
      • Cools A.M.
      Does adding heavy load eccentric training to rehabilitation of patients with unilateral subacromial impingement result in better outcome? A randomized, clinical trial.
      • Marzetti E.
      • Rabini A.
      • Piccinini G.
      • et al.
      Neurocognitive therapeutic exercise improves pain and function in patients with shoulder impingement syndrome: A single-blind randomized controlled clinical trial.
      • Pastora-Bernal J.M.
      • Martin-Valero R.
      • Baron-Lopez F.J.
      • Moyano N.G.
      • Estebanez-Perez M.J.
      Telerehabilitation after arthroscopic subacromial decompression is effective and not inferior to standard practice: Preliminary results.
      • Subaşi V.
      • Toktaş H.
      • Demirdal U.S.
      • Türel A.
      • Çakir T.
      • Kavuncu V.
      Water-based versus land-based exercise program for the management of shoulder impingement syndrome.
      2 compared open with arthroscopic decompression,
      • Husby T.
      • Haugstvedt J.R.
      • Brandt M.
      • Holm I.
      • Steen H.
      Open versus arthroscopic subacromial decompression: a prospective, randomized study of 34 patients followed for 8 years.
      ,
      • Spangehl M.J.
      • Hawkins R.H.
      • McCormack R.G.
      • Loomer R.L.
      Arthroscopic versus open acromioplasty: A prospective, randomized, blinded study.
      2 compared glucocorticoid injection with or without ultrasound guidance,
      • Bhayana H.
      • Mishra P.
      • Tandon A.
      • Pankaj A.
      • Pandey R.
      • Malhotra R.
      Ultrasound guided versus landmark guided corticosteroid injection in patients with rotator cuff syndrome: Randomised controlled trial.
      ,
      • Cole B.F.
      • Peters K.S.
      • Hackett L.
      • Murrell G.A.
      Ultrasound-guided versus blind subacromial corticosteroid injections for subacromial impingement syndrome: A randomized, double-blind clinical trial.
      1 compared 1 to 2 glucocorticoid injections,
      • Akgün K.
      • Birtane M.
      • Akarirmak Ü.
      Is local subacromial corticosteroid injection beneficial in subacromial impingement syndrome?.
      and 1 compared glucocorticoid injection with or without lidocaine.
      • Kim S.J.
      • Lee H.S.
      Lidocaine test increases the success rates of corticosteroid injection in impingement syndrome.
      Based on the forest plots provided and comparisons within the studies, it appears that only single unidentified arms of these studies were pooled, violating the principle inherent in network meta-analyses of maintaining within study randomization. It is highly likely that the transitivity assumption was violated for numerous reasons, including the differing time points of evaluation across the individual studies. It was also unclear why the multidimensional instruments of function (American Shoulder and Elbow Surgeons Society Shoulder Score, Simple Shoulder Test, Oxford Shoulder Score, Shoulder Pain and Disability Index, and the University of California–Los Angeles Shoulder Rating Scale) were not pooled. Minimally important differences are known to vary depending on the context, including the populations and treatments being compared. As the review did not include a synthesis of the potential harms of therapy or weigh these against the potential to benefit, it also makes it difficult to contextualize the clinical importance of any observed differences in effects between treatments.
      We recommend that systematic reviewers and particularly those planning to perform network meta-analyses follow the guidance recommended by Cochrane.

      Chaimani A, Caldwell DM, Li T, Higgins JPT, Salanti G. Chapter 11: Undertaking network meta-analyses. In: Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA, eds. Cochrane Handbook for Systematic Reviews of Interventions, version 6.3 (updated February 2022). Cochrane, 2022. Available from www.training.cochrane.org/handbook

      We also would not attempt network meta-analyses without a biostatistician with expertise in these analyses. For a start, the search strategy could be vastly improved by limiting the search with the use of “AND” as well as “OR” terms. We also suggest limiting inclusion to randomized controlled trials using a validated search strategy for identifying them such as the one recommended by Cochrane,
      • Lefebvre C.
      • Glanville J.
      • Briscoe S.
      • et al.
      Chapter 4: Searching for and selecting studies.
      and validated search strategies for identifying subacromial pain syndrome also exist.
      • Page M.J.
      • Green S.
      • McBain B.
      • et al.
      Manual therapy and exercise for rotator cuff disease.
      ,
      • Karjalainen T.V.
      • Jain N.B.
      • Heikkinen H.
      • Johnston R.V.
      • Page C.M.
      • Buchbinder R.
      Surgery for rotator cuff tears.
      At a minimum, there should be a description of the characteristics of included studies and their individual potential for bias, as well as a list of excluded trials with reasons for exclusion. Readers also should be able to understand which studies contribute to each comparison, and an assessment of the certainty of evidence as per the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach would inform the reader about how much they can trust in each effect.
      • Schünemann H.J.
      • Oxman A.D.
      • Higgins J.P.
      • et al.
      on behalf of the Cochrane GRADEing Methods Group and the Cochrane Statistical Methods Group. Chapter 11: Completing ‘Summary of findings’ tables and grading the confidence in or quality of the evidence.
      So how should we proceed from here? We owe it to our patients to change our practice when there is compelling evidence that such a change will improve their outcomes. As the weight of the evidence has now shifted toward an understanding that surgery offers no discernible benefits to people with impingement symptoms but may result in harm, it is disheartening that some guidelines continue to recommend surgery.
      • Hohmann E.
      • Shea K.
      • Scheiderer B.
      • Millett P.
      • Imhoff A.
      Indications for arthroscopic subacromial decompression. A Level V evidence clinical guideline.
      The reasons are likely multifactorial, but some important reasons likely include confirmation bias, or the tendency to be more accepting of evidence that confirms our existing beliefs while finding flaws in evidence that is contrary to them; a lack of science literacy that is essential for being able to discern rigorous from untrustworthy evidence; miracle thinking that results in overestimating benefits and underestimate harms; and the perverse incentives that often exist that favor active treatment.
      • Buchbinder R.
      • Harris I.
      Hippocrasy: How doctors are betraying their oath.
      Rather than resorting to futile surgery as a last resort for people with persistent symptoms, it would be good to remember that “to do nothing is also a good remedy” (quote attributed to Hippocrates). For those who say that surgery is not futile in their subgroup of patients, the onus is on them to establish the truth, although finding these subgroups has proven elusive for other types of arthroscopic surgery.
      • Pihl K.
      • Ensor J.
      • Peat G.
      • et al.
      Wild-goose chase, no predictable patient subgroups who benefit from meniscal surgery: Patient-reported outcomes of 641 patients 1 year after surgery.

      Supplementary Data

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