The Pro sports blog
The material provided here is general information and individual advice should be obtained with an evaluation or assessment by an appropriate physical therapist
Journal Club- Subacromial Decompression Yields a Better Clinical Outcome Than Therapy Alone; A Prospective Randomized Study of Patients With a Minimum 10-Year Follow-Up - AJSM 2018:46(6)
Jamie Ferraro, SPT, CSCS
Subacromial Impingement Syndrome (SAIS) is the most common pathology of the shoulder. The subacromial space of the shoulder joint is made up of the humeral head inferiorly, the acromion anteriorly, and both the coracoacromial ligament and acromioclavicular joint superiorly. The space between the humeral head and the acromion ranges from 1.0-1.5 centimeters, and is occupied by the tendons of the rotator cuff, long head of biceps tendon, a bursa, and the coracoacromial ligament. SAIS may occur when there is an abnormality leading to a disruption in the relationship of these structures.
SAIS can be categorized into three stages. Stage I is typically found in individuals under 25 years old, and it involves edema and hemorrhage of the bursa and the rotator cuff. Stage II is more often found in 25-40 year olds and involves irreversible changes of the rotator cuff, such as fibrosis and tendonitis. Stage III involves chronic changes of the rotator cuff, including partial or complete tears, and is more often found in individuals over 40 or those who have an occupation that involves increased arm abduction. Currently, the treatment for early stages of SAIS consists of conservative methods, such as physical therapy, NSAIDs, or cortisone injections. If these methods fail or the SAIS is more severe, a subacromial decompression operation may be performed. Originally this procedure was performed as an open acromioplasty, however since the 1980’s surgeons have transitioned to an arthroscopic technique.
This study hypothesized that individuals with Stage I and II SAIS who underwent either an open or arthroscopic subacromial decompression would demonstrate a better long-term outcome after a minimum of 10 years, and run a lower risk of developing rotator cuff ruptures and osteoarthritis compared to patients who only participated in physical therapy. The authors based this study off of a previously reported short-term study after a 2.5-year follow up. The results showed that patients in both surgical groups showed better clinical results than those in the physical therapy only group.
There are some limitations in this study that should be considered. The sample size and follow-up rate in this study was very low, and the outcome measurements were assessed by a different physical therapist than the one who gathered the baseline measurements. Secondly, the physical therapy group was supervised by five difference physical therapists. Although they were all following the same protocol, the rate of progression and instruction technique is unknown and may not have been standardized. Additionally, the only objective measurements of strength were taken in abduction, and the range of motion tested in all groups was limited to flexion and internal rotation.
For both physical therapists and patients with SAIS, it is important to consider all of the available literature before selecting to undergo a surgical treatment option. SAIS may present differently in every patient and further studies have shown conflicting evidence, stating sham surgery offers no benefits compared to both subacromial decompression surgeries and non-operative treatments. Therefore, it is important to follow up on all of the research to remain educated on all possibilities to make an informed decision.
Beard DJ, et. al. Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW): a multicentre, pragmatic, parallel group, placebo-controlled, three- group, randomised surgical trial. Egyptian Journal of Medical Human Genetics. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)32457- 1/fulltext. Published November 20, 2017.
Farfaras S, Sernert N, Rostgard L, Hallström EK, Kartus JT. Subacromial Decompression Yields a Better Clinical Outcome Than Therapy Alone: A Prospective Randomized Study of Patients With a Minimum 10-Year Follow-up. https://www.ncbi.nlm.nih.gov/pubmed/29543510. Published May 2018.
Umer M, Qadir I, Azam M. Subacromial impingement syndrome. Orthopedic Reviews. 2012;4(2):e18. doi:10.4081/or.2012.e18.