Shoulder surgery: is it the best way to restore joint stability and function?

When managing our athletes with an injury we have deeply ingrained desire to return to play within the shortest time. This can drive our treatment choices, with surgical options often viewed as the best way to restore joint stability and function. 

Shoulder pain is common —with up to 25% of adults experiencing some form of shoulder discomfort over the last 12 months. The shoulder is structurally complex and allows a huge range of motion but with this comes decreased stability so it’s prone to pain and injury. I don’t think there are many CrossFitters who have not experienced an episode of shoulder pain at some stage during their training.

Two of the most frequently performed shoulder procedures are subacromial decompression and labral tear repair. But how strong is the evidence we base the decision to operate on and how does surgery compare to physiotherapy or placebo?

The majority of cases of shoulder pain are non-traumatic, with pain localised around the acromion and exacerbated by moving the arm. The subacromial bursa and rotator cuff muscle tendons lie within the subacromial space.  Subacromial pain syndrome (SAPS) describes pain associated with any of the structures within this space and is often attributed to mechanical contact or impingement of the rotator cuff tendons between the humeral head and the overlying acromion. Various clinical and radiological diagnoses such as bursitis, tendinosis, supraspinatus tendinopathy, rotator cuff tears or degeneration and biceps tendonitis are all part of SAPS.

Subacromial decompression surgery aims to widen the space where the tendons pass, this can include shaving off part of the acromion (acromioplasty), removing the bursa, repair of rotator cuff tendons and release of the coracoacromial ligament. Over the last 10 years in England, the use of this procedure has increased by around 90%, with estimates that nearly 21,000 are carried out each year.

Clinical guidelines are inconsistent but most recommend surgery for significant and persistent symptoms that have not responded to conservative measures (steroid injections and physiotherapy). However, there is significant debate about the effectiveness of this procedure with several trials failing to show any benefit.

A systematic review published in 2019 looked at the data from 8 trials. Two compared subacromial decompression with arthroscopy only (placebo surgery). The other trials compared surgery and exercise to exercise alone. The data strongly suggests that subacromial decompression does not reduce pain, improve function, or quality of life when compared to placebo surgery or exercise alone.

Injury to the shoulder labrum is commonly seen in athletes, especially in those involved in throwing or overhead activities. The shoulder labrum is a ring of cartilage around the shoulder socket that stabilises the humeral head. The upper part of the labrum attaches to the biceps tendon. A superior labrum anterior and posterior (SLAP) tear describes an injury to the front and back of the labrum where it attaches to the biceps tendon. 

Surgical repair is often recommended for refractory pain or mechanical symptoms particularly in younger patients or those who will place a greater demand on the shoulder joint. However, the optimal treatment of SLAP injuries is not known, with significant complication rates and inability to return to play (RTP) often seen postoperatively.

A 2010 systematic review found varying success rates between 40-90% and RTP rates from 20-94% with better results seen in athletes not involved in overhead throwing activities and higher failure and complication rates are seen in patients over 40 years. A further 2010 study showed similar RTP rates in athletes managed conservatively compared to those who had surgery.

A small 2014 study in professional baseball players suggests that non-surgical treatment with exercise-based programs has a reasonable RTP success rate when compared to surgery.

Another 2017 trial compared labral repair to sham/placebo surgery. The results showed no significant clinical benefit to surgical repair over sham surgery. When faced with this evidence from multiple trials why then is the rate of surgical intervention so high?

In addition, no surgical procedure is without risks and while rates of serious adverse events including; infection, bleeding, blood clots and nerve injuries are low (<1%), minor adverse events including frozen shoulder and minor surgical complications are seen in 3%. The postoperative rehabilitation process can take anywhere from 3-6 months. 

When managing our patients, we need to recognise that anatomical and biomechanical pathology is poorly correlated to pain. 40% of middle-aged patients will have asymptomatic rotator cuff pathology on MRI and there’s about a 50% correlation between knee osteoarthritis and pain. 

A small study on the shoulders of elite volleyball players published last year used MRI to detect asymptomatic shoulder pathology in their dominant arm. Of these 26 athletes, 88.5% had rotator cuff tendinosis, 65.4% had partial rotator cuff tears, 23.1% had a labral tear and a further 23.1% had labral fraying. None of the athletes had a normal MRI but despite this, they were still competing and pain-free.

At times patients will have significant pain with normal or minor abnormalities on imaging. The main premise of orthopaedic surgery is to correct faulty anatomy or biomechanics with resultant pain relief — the tissue-based model of pain, i.e tissue damage/pathology is painful. If this is the case, then, in the absence of significant clinical findings and with fairly normal imaging then surely, it is hard to justify the risks of surgery. 

Over the last 10 years, there have been a number of trials comparing various orthopaedic procedures to placebo surgery. While not all of these trials are of high quality (small sample sizes, confounding factors at baseline), when viewed collectively I don’t think you can deny there is increasing evidence that sham surgery is often as effective as corrective procedures and that good rehab could be equally as effective.

When should we operate? Undoubtedly there are many cases where surgery is successful. How do we identify these people? There is significant evidence that subacromial decompression surgery provides no clinical benefit and SLAP repair surgery may be helpful only in carefully selected cases. We need to recognise that most treatment decisions are made by consensus between the clinician and patient and these are based on empiric knowledge rather than a substantial evidence base. Surgery should be reserved for selected patients after a comprehensive trial of rehab and physio. There should also be significant tissue/joint damage which surgery aims to correct. There should be a full and frank discussion with each individual regarding the evidence base for the proposed procedure along with risks that are involved.

References:

Vandvik PO, Lahdeoja T, Ardern C, Buchbinder R, Moro J, Brox JI et al. Subacromial decompression surgery for adults with shoulder pain: a clinical practice guideline BMJ 2019;364:l294 doi: https://doi-org.ergo.southwales.ac.uk/10.1136/bmj.l294

Diercks R, Bron C, Dorrestijin O, Meskers C, Naber R, De Ruiter T, Willems J, Winters J, Van der Woude H. Guideline for diagnosis and treatment of subacromial pain syndrome. A multidisciplinary review by the Dutch Orthopaedic Association Acta Orthop. 2014 Jun; 85(3): 314–322.doi: 10.3109/17453674.2014.920991

Jones T, Carr AJ, Beard D, Linton MJ, Rooshenas L, Donovan J, Hollingworth W. Longitudinal study of use and cost of subacromial decompression surgery: the need for effective evaluation of surgical procedures to prevent overtreatment and wasted resources. BMJ Open 2019;9:e030229. doi:10.1136/ bmjopen-2019-030229

2014 Commissioning guide: Subacromial Shoulder Pain. British Orthopaedic Association

https://www.boa.ac.uk/uploads/assets/uploaded/f4bfe04a-0450-4eab-b9acad9dbb5d8c86.pdf

Karjalainen TV, Jain NB, Page CM, Lahdeoja TA, Johnston RV, Salamh P, Kavaja L, Arden C, Agarwal A, Vandvik PO, Buchbiner R. Subacromial decompression surgery for rotator cuff disease. Cochrane Systematic Review - Intervention Version published: 17 January 2019 .https://doi.org/10.1002/14651858.CD005619.pub3

Familiari F, Huri G, Simonetta R, McFarland EG. SLAP lesions: current controversies. EFORT Open ReviewsVol. 4, No. 1 Shoulder & Elbow

Open Access. Published Online:28 Jan 2019https://doi.org/10.1302/2058-5241.4.180033

Erickson J, Lavery K, Monica J, Gatt C, Dhawan A. Surgical treatment of symptomatic superior labrum anterior-posterior tears in patients older than 40 years: a systematic review. Am J Sports Med. 2015;43(5):1274. Epub 2014 Jun 24. 

Provencher MT, McCormick F, Dewing C, McIntire S, Solomon D. A prospective analysis of 179 type 2 superior labrum anterior and posterior repairs: outcomes and factors associated with success and failure. Am J Sports Med. 2013 Apr;41(4):880-6. Epub 2013 Mar 4. 

Gorantla K, Gill C, Wright RW. The Outcome of Type II SLAP Repair: A Systematic Review. Arthroscopy. 2010 Apr;26(4):537-45. doi: 10.1016/j.arthro.2009.08.017. Epub 2010 Jan 25.

Edwards SL, Lee JA, Bell JE, Packer JD, Ahmad CS, Levine WN, Bigliani LU, Blaine TA. Nonoperative Treatment of Superior Labrum Anterior Posterior Tears: Improvements in Pain, Function, and Quality of Life. Am J Sports Med Volume: 38 issue: 7, page(s): 1456-1461. https://doi.org/10.1177/0363546510370937

Fedoriw WW, Ramkumar P, McCulloch PC, Linter DM. Return to Play After Treatment of Superior Labral Tears in Professional Baseball Players. Am J Sports Med Volume: 42 issue: 5, page(s): 1155-1160. https://doi.org/10.1177/0363546514528096

Schrøder CP, Skare O, Reikerås O, Mowinckel P, Brox JI. Sham surgery versus labral repair or biceps tenodesis for type II SLAP lesions of the shoulder: a three-armed randomised clinical trial. Br J Sports Med 2017 Dec;51(24):1759-1766. doi: 10.1136/bjsports-2016-097098. Epub 2017 May 11.

Lee CS, Goldhaber NH, Davis SM, Dilley ML, Brock A, Wosmek J, Lee EH, Lee RK, Stetson WB. Shoulder MRI in asymptomatic elite volleyball athletes shows extensive pathology Journal of ISAKOS: Joint Disorders & Orthopaedic Sports Medicine 2020;5:10-14.