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Subacromial decompression surgery for adults with shoulder pain: a clinical practice guideline

BMJ 2019; 364 doi: https://doi.org/10.1136/bmj.l294 (Published 06 February 2019) Cite this as: BMJ 2019;364:l294

Linked Editorial

Subacromial decompression surgery for shoulder pain

Visual summary of recommendation

or Subacromial decompression surgery Nonoperativemanagement only Arthroscopic subacromial decompression plusnonoperative management Including guided physical therapy, exercise programmes, NSAIDs, and steroid injections Interventions compared Recommendation Population Adults with shoulderpain for more than 3 months Does not apply to patients with: Including: Traumatic shoulder pain Subacromial pain syndrome (SAPS) Rotator cuff disease (RCD) Other differential diagnoses

We recommend against subacromial decompression surgery Moredetails Strong All or nearly all informed people would likely want this option. Benefits outweigh harms for almost everyone. Weak Most people would likely want this option. Benefits outweigh harms for the majority, but not for everyone. Weak Most people would likely want this option. Benefits outweigh harms for the majority, but not for everyone. Strong All or nearly all informed people would likely want this option. Benefits outweigh harms for almost everyone.

Comparison of benefits and harms

Favours surgery Evidence quality Visual analogue scale (0–10) After 1 year No important difference The panel found that this difference was not important for most patients, because the intervention effects were negligible and/or very imprecise, for example confidence intervals that include both important benefit and harm Favours nonoperative management Evidence presented here shows the comparison between surgery and placebo surgery (diagnostic arthroscopy). Higher quality evidence was available for this comparison than for surgery versus nonoperative management, and the authors believe it is therefore a more useful guide to the effectiveness of surgery. Lower quality evidence on surgery versus nonoperative management is available in MAGIC app, using the link at the bottom of the graphic

No important difference Pain (Mean) High More 2.6 2.9

Risk of Bias No serious concerns Imprecision No serious concerns Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns Surgery has little or no effect on pain at 1 year A separate review found that the “minimally important difference” for patients would be an improvement of 1.5 on this scale 1.5 MID High GRADE score, because of: GRADE certainty ratings The authors have a lot of confidence that the true effect is similar to the estimated effect The authors believe that the true effect is probably close to the estimated effect High The true effect might be markedly different from the estimated effect The true effect is probably markedly different from the estimated effect Moderate Low Very low

Constant score scale (0–100) No important difference Function (Mean) High More 72 69

A separate review found that the “minimally important difference” for patients would be an improvement of 8.3 on this scale 8.3 MID Risk of Bias No serious concerns Imprecision No serious concerns Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns Surgery has little or no effecton function at 1 year High GRADE score, because of: GRADE certainty ratings The authors have a lot of confidence that the true effect is similar to the estimated effect The authors believe that the true effect is probably close to the estimated effect High The true effect might be markedly different from the estimated effect The true effect is probably markedly different from the estimated effect Moderate Low Very low

No important difference EQ-5D scale (-0.59–1) Quality of life (Mean) High More 0.70 0.73

A separate review found that the “minimally important difference” for patients would be an improvement of 0.07 on this scale 0.07 MID Risk of Bias No serious concerns Imprecision No serious concerns Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns Surgery has little or no effecton quality of life at 1 year High GRADE score, because of: GRADE certainty ratings The authors have a lot of confidence that the true effect is similar to the estimated effect The authors believe that the true effect is probably close to the estimated effect High The true effect might be markedly different from the estimated effect The true effect is probably markedly different from the estimated effect Moderate Low Very low

635 Global perceived effect Moderate More Events per 1000 people No important difference 699

Risk of Bias No serious concerns Imprecision Serious Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns Surgery probably has little or no global perceived effect at 1 year Moderate GRADE score, because of: GRADE certainty ratings The authors have a lot of confidence that the true effect is similar to the estimated effect The authors believe that the true effect is probably close to the estimated effect High The true effect might be markedly different from the estimated effect The true effect is probably markedly different from the estimated effect Moderate Low Very low

No important difference At work Low More 859 818 Number of participants working at the time of outcome assessment

Risk of Bias No serious concerns Imprecision Very serious Indirectness No serious concerns Inconsistency No serious concerns Publication bias No serious concerns Surgery may have little or no effect on whether a person is working after 1 year Low GRADE score, because of: GRADE certainty ratings The authors have a lot of confidence that the true effect is similar to the estimated effect The authors believe that the true effect is probably close to the estimated effect High The true effect might be markedly different from the estimated effect The true effect is probably markedly different from the estimated effect Moderate Low Very low
Events per 1000 people Within 30 days

6 fewer 0 Serious harms Moderate More 6

Risk of Bias No serious concerns Imprecision No serious concerns Indirectness Serious Inconsistency No serious concerns Publication bias No serious concerns Surgery probably slightly increases risk of serious harms Moderate GRADE score, because of: Data from a well performed registry study of mixed surgical procedures, resulting in indirectevidence for subacromial decompression Observed harms include: Deep vein thrombosis (20.0%) Pulmonary embolism (18.6%) Pneumonia (13.8%) Sepsis and serious infections (9.0%) Bleeding transfusion (8.3%) GRADE certainty ratings The authors have a lot of confidence that the true effect is similar to the estimated effect The authors believe that the true effect is probably close to the estimated effect High The true effect might be markedly different from the estimated effect The true effect is probably markedly different from the estimated effect Moderate Low Very low
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Recovery time varies from months to years and may include sick leave Day surgery with general anaesthesia and/or nerve block After surgery, 2 weeks off work are typically needed Avoid heavy lifting for one to three weeks, overhead activities for 3 months The panel believes that all or almost all patients would place a high value on avoiding even minimal risk of complications and burden from surgery, if it is not helpful. Values and preferences Key practical issues Surgery Nonoperative management

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Re: Subacromial decompression surgery for adults with shoulder pain: a clinical practice guideline

I have over 50 years' experience treating patients with shoulder pain. In the 1970s and 1980s, those patients who presented with a painful arc in flexion and /or abduction invariably also have (on "hands on" clinical examination) signs of cervical spine involvement.

Frequently, the clinician can see (if the patient is viewed from behind) overactivity of Levator scapula during the movement of abduction. There is also frequently (if the condition has been present for some time) wasting of one or more rotator cuff muscles.

Palpation of the cervical spine usually elicits tenderness and stiffness of cervical facet joints on the symptomatic side from C2 to C5.

Mobilisation of these for 1-2 minutes will usually either eliminate or significantly reduce the painful arc.

The now almost universal referral by general practitioners of patients for ultrasound scans viewing only the symptomatic shoulder (and not the painless shoulder as well) has given rise to the mis-diagnosis of "subacromial bursitis", referral to orthopaedic surgeons and subsequent decompression surgery, often without a prior trial of conservative treatment.

I applaud this article and hope it will encourage a more enlightened approach to the management of shoulder pain.

Competing interests: No competing interests

05 June 2019
Douglas E. Morphett
Muscluoskeletal Physiotherapist
Secret Habour Australia WA 6173
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