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Shoulder Impingement Syndrome: Will Surgery Make a Difference?

Shoulder impingement syndrome (SIS) is one of the most common causes of chronic shoulder pain in adults, and one that is frequently seen in primary care. Typical symptoms include pain with overhead movements, and classic physical exam tests include Neer’s sign, Hawkins-Kennedy sign, and a painful arc.

Pain from shoulder impingement is thought to be secondary to impingement of the rotator cuff tendons due to decreased subacromial space. Subacromial space can be reduced due to multiple reasons:

  • Poor posture creating a protracted shoulder girdle with internally rotated glenohumeral joint, creating a functionally reduced subacromial space
  • Subacromial bursitis, either acute or chronic (although this can also be seen secondary to the former point)
  • Spurring of the inferior surface of the acromion

Treatment of shoulder impingement syndrome typically involves:

  • Physiotherapy to develop pain-free ROM, strengthening of the rotator cuff and periscapular muscles, improved posture, and improved scapular kinetics
  • Oral NSAIDs are commonly prescribed
  • Corticosteroid injection of the subacromial bursa can be considered if pain is severe or the patient has failed a trial of more conservative management

What about surgery?

  • Arthroscopic subacromial decompression is a commonly performed surgery
  • It typically involves shaving down the inferior aspect of the acromion, thereby creating a larger subacromial space
  • A Cochrane review concluded that evidence does not support subacromial decompression surgery as a treatment for shoulder impingement, as it does not provide clinically meaningful benefits in terms of pain relief1
  • The BMJ released a clinical practice guideline strongly recommending against subacromial decompression surgery for the treatment of shoulder pain2
  • More recently, an RCT published in the British Journal of Sports Medicine that involved 5 year follow-up failed to detect any difference in pain between patients who underwent subacromial decompression, patients who underwent diagnostic arthroscopy (placebo surgery), or patients who completed an exercise program3

Bottom line?

Evidence suggests that there is no benefit to subacromial decompression surgery for the treatment of shoulder impingement. Patients with this condition should be reassured that surgery is unlikely to help their symptoms, and that treatment should focus on conservative management.

Janet Barber MD, MSc, BSc

PGY3 Sport and Exercise Medicine, University of Ottawa

Advisor: Dr Taryn-Lise Taylor BKin, MSc, MD, CCFP (SEM), Dip Sport Med

References:

  1. Karjalainen, T. V., Jain, N. B., Page, C. M., Lähdeoja, T. A., Johnston, R. V., Salamh, P., … & Buchbinder, R. (2019). Subacromial decompression surgery for rotator cuff disease. Cochrane Database of Systematic Reviews, (1).
  2. Vandvik, P. O., Lähdeoja, T., Ardern, C., Buchbinder, R., Moro, J., Brox, J. I., … & Noorduyn, J. (2019). Subacromial decompression surgery for adults with shoulder pain: a clinical practice guideline. Bmj364.
  3. Paavola, M., Kanto, K., Ranstam, J., Malmivaara, A., Inkinen, J., Kalske, J., … & Järvinen, T. L. (2020). Subacromial decompression versus diagnostic arthroscopy for shoulder impingement: a 5-year follow-up of a randomised, placebo surgery controlled clinical trial. British journal of sports medicine.
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