Clinical Guideline for Shoulder Pain

senior man with shoulder pain
senior man with shoulder pain
A clinical practice guideline for the use of subacromial decompression surgery in adults with atraumatic shoulder pain and subacromial pain syndrome.

A guideline panel consisting of patients, clinicians, and methodologists has created a clinical practice guideline for the use of subacromial decompression surgery in adults with atraumatic shoulder pain and subacromial pain syndrome (SAPS). The guidelines were published in the BMJ.

In current clinical practice, simple analgesia (eg, paracetamol, nonsteroidal anti‐ inflammatory drugs [NSAIDs], glucocorticoid injections, and exercise therapy) is the first-line option for SAPS, but patients with long-term symptoms associated with SAPS may require subacromial acromial decompression surgery as a second-line strategy. This surgery removes the subacromial bursa as well as bone under the surface of the acromion.

To develop key clinical guidelines for the management of SAPS using subacromial acromial decompression, an international panel of patients with shoulder pain, orthopedic surgeons, physiotherapists, general internists, epidemiologists, and methodologists was convened. The panel sought to identify important outcomes following intervention (eg, pain, patient global perceived benefit, participation in work and recreational activities). The recommendations were formulated based on 2 systematic reviews investigating the benefits and harms of subacromial decompression surgery, including improvements in pain, function, and quality of life in individuals with SAPS.

The Minimally Important Difference (MID) in Symptoms and Function

In 22 studies including 5562 participants, patients with shoulder pain indicated a difference in pain of ≥1.5 unit as being important. A difference in function of ≥8.3 units was considered important. There was less confidence in defining a difference in health-related quality of life as important (0.07 unit).

Benefits and Harms of Subacromial Decompression Surgery

A total of 7 randomized-controlled trials (n=1014) were identified in which the harms and benefits of surgery were examined. Patients included in the trials were seen at primary care centers and outpatient clinics and had SAPS. Placebo-controlled trials with lower risk for bias indicated no meaningful difference between placebo and surgery at 1 year, particularly for pain (mean difference, −0.26; 95% CI, −0.84 to 0.33; MID, 1.5), function (mean difference, 2.8; 95% CI, −1.4 to 6.9; MID, 8.3), and health-related quality of life (mean difference, −0.03 point; 95% CI, −0.11 to 0.06; MID, 0.07). In 6 trials, no surgery-associated benefits were found for pain, function, quality of life, global perceived effect, and return to work, compared with exercise therapy.

Trials did not report harms associated with subacromial decompression surgery completely. The risk for serious harms following mixed shoulder arthroscopic procedures in 4 observational trials was 0.5% (95% CI, 0.4%-0.7%) from 2006 to 2011 and 0.6% (95% CI, 0.5%-0.7%) from 2011 to 2013. Harms associated with surgery included major bleeding, deep infections, serious anesthetic complications, venous thromboembolism, and peripheral nerve injury.

Panel Recommendations

Well-informed patients should decline subacromial decompression surgery based on the available evidence. No superior benefit was found for surgery in comparison with other interventions, including placebo and exercise therapy. Clinicians should not recommend this surgical option to patients without clearly explaining the research behind the treatment. Considering the costs associated with surgery and the lack of benefit, clinicians should inform patients about the ineffectiveness of subacromial decompression for SAPS.

“Glucocorticoid injections and NSAIDs may provide moderate to small short-term benefits on shoulder pain compared with placebo. Exercise, manual therapy, and electrotherapies are of uncertain benefit to patients compared with watchful waiting, and guidelines vary in their recommendations,” noted the panel.

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Vandvik PO, Lähdeoja T, Ardern C, et al. Subacromial decompression surgery for adults with shoulder pain: a clinical practice guideline. BMJ. 2019;364:l294.