Posts tagged shoulder surgery
Should I Undergo Surgery Or Physical Therapy For My Shoulder Pain?
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Shoulder pain remains one of the top 3 reasons patients seek care from their primary care physician and Physical Therapist. The most common diagnosis causing pain among these patients is subacromial impingement syndrome. Impingement can be found along with rotator cuff tendon pain (tendinopathy) or partial rotator cuff tears on clinical exam and imaging. Impingement is often found in patients with rotator cuff and scapular muscle weakness leading to pain and loss of arm function. Physical Therapy remains the first line of treatment for impingement but surgery has also been utilized to treat this condition. A recent review of the literature compared these two approaches.

Nazari and colleagues compared the available research on the effectiveness of Physical Therapy vs. shoulder surgery for patients with impingement (PLoS One. 2019). Authors included 11 randomized controlled trials including over 900 patients with follow up periods up to 10 years after the interventions were performed. Authors reported no difference in outcomes between Physical Therapy vs. Surgery plus post operative Physical Therapy at short or long term follow up periods. Based on this review of the literature Physical Therapy remains a first line treatment for shoulder pain.

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What imaging pathologies are associated with shoulder pain?
shoulder-MRI-findings-pain-diagnosis

MRI testing of the shoulder is no different than testing in other body regions.  Pathologies such as bursa changes, tendinopathies, labral and rotator cuff tears are very common in asymptomatic populations and tend to increase with an individual's age.  Many of these MRI findings do not contribute to a patient's current symptoms and may be reflective instead of the natural aging process in the shoulder.  Conversely, some pathologies such as rotator cuff tears may explain a patient's symptoms especially when these findings match the patient's subjective history or clinical examination.

Tran and colleagues sought to answer this question by reviewing the available evidence on shoulder MRI findings and a patient's symptoms and prognosis (Arthritis Care Res. 2018).  Authors reviewed 56 papers and found no significant association between most imaging findings and current symptoms.  One exception was enlarging rotator cuff tears which were shown to be associated with an increased incidence of symptoms.  In general, the majority of these studies were low in quality and authors called for high quality studies on this topic.  

What happens to unrepaired full thickness rotator cuff tears?
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In our previous blog post we described how few (16%) partial rotator cuff tears progress over time.  Understanding the non progressive nature of the injury allows patients an opportunity to explore non surgical options including Physical Therapy.  In this study they followed partial rotator cuff tears over time, but a more recent study followed patients with full thickness rotator cuff tears over a 5 year period.

Boorman and colleagues followed patients with chronic (> 3 months), full thickness rotator cuff tears (J Shoulder Elbow Surg. 2018).  All patients participated in a comprehensive, Physical Therapy home exercise program.  At 3 months, patients were categorized at successful (asymptomatic with Physical Therapy home exercises) or failure (continued pain and dysfunction).  These patients were then referred for surgical consultation.

At 5 years, 84% of all patients were contacted to determine their current symptoms and functional level.  75% of patients treated non operatively remained asymptomatic with their strengthening program.  Only 3 patients who were initially asymptomatic at 3 months required surgery over the 5 year follow up period.  Importantly, the authors noted no difference in functional outcomes at 5 years between those patients treated surgically or with a home Physical Therapy exercise program.  The authors concluded "non operative treatment is an effective and lasting option for many patients with a chronic, full thickness rotator cuff tear."  This study and our previous blog post challenge the belief that non operative interventions only delay eventual surgical interventions because very few tears regress and very few patients eventually undergo surgical repair.

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Few Rotator Cuff Tears Worsen Over Time
boulder-rotator-cuff-surgery

Previous research has found no significant difference at either 1 or 2 year follow up between Physical Therapy or surgery for rotator cuff tears.  One disproven argument you may still hear against the conservative care of these tears is they may worsen over time including larger tear sizes or further movement of the torn ends (retraction) limiting surgical effectiveness.  This is a logical thought until we consider what the research shows on the progression of these tears.

An article in the American Journal of Sports Medicine followed 362 patients with high grade partial rotator cuff tears to determine the natural progression or regression of these tears over time.  These patients were followed with conservative care including Physical Therapy for up to one year before undergoing a second MRI scan to determine if there were any changes in the torn tendon.  81 patients underwent the second MRI scan.  The authors reported only 16% of patients had a progression of their tear.  Conversely, 60% of patients showed no change in the tear size and 25% of tears improved over time.  Authors stated "decisions to undertake surgery at the time of presentation may be excessive".  

This study highlights the importance of using Physical Therapy first for rotator cuff tears.  Schedule your first appointment with the experts at MEND now/ 

No Difference Between Surgery and Placebo Surgery for Shoulder Pain
boulder-shoulder-surgery-treatment

We have previously written about the move away from arthroscopic surgery for degenerative meniscal tears and knee arthritis based on surgery's limited effectiveness in the medical research.  In addition, these surgeries have not been able to show greater outcomes than placebo or sham surgery.  Until recently, studies have not utilized a comparable placebo group to orthopedic surgery but the results of these procedures on common knee and now shoulder conditions have been thought provoking.

Impingement or the compression of the rotator cuff tendons and bursa between the arm bone and shoulder blade (subacromial space) is the most common diagnosis behind shoulder pain.  This condition is successfully treated with Physical Therapy interventions including manual therapy and exercise, but a subset of patients undergo decompression shoulder surgery.  A recent research article compared the effectiveness of this surgery to both a no treatment/control group and a placebo surgery.

boulder-shoulder-surgery-treatments

Beard and colleagues conducted a large, multi centered, randomized controlled trial of 313 patients with shoulder impingement (Lancet, 2017).  Patients were randomized to either a decompression surgery, a sham surgery, or a no treatment group.  Both surgical groups received post operative Physical Therapy.  Surprisingly, there were no significant long term differences between either surgical group and the control group.  In addition, there was no significant difference between the surgical and placebo surgery groups.  The authors concluded the study findings call into question the value of surgery for patients with this subset of shoulder pain.

Relationship of Age and Rotator Cuff Repair Failure
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Evidence demonstrates equal long term outcomes between Physical Therapy and surgery for non traumatic rotator cuff tears.  Patient's most appropriate for surgical repair include patients with larger tears, greater disability and limitations with arm use, and those with a low expectation for recovery with conservative care.  Among those patients opting for surgical interventions up to 1 in 3 will have a re tear of their surgically repaired shoulder.  The odds of re tearing the rotator cuff increase with age and greater numbers of rotator cuff tendon involvement.  A recent study examined the impact of age on the risk of re tearing the rotator cuff repair. 

Diebold and colleagues studied 1600 patients who underwent arthroscopic rotator cuff repair (JBJS. 2017).  Patient underwent a diagnostic ultrasound at 6 months to determine the integrity of the cuff repair.  212 or 13% of patients had a retear at follow up, but the rate of retear was <5% in patients under 50 years old.  The rate of re tear increased with each decade of life from 10% in patients aged 50-59 y.o. to 34% in patients > 80 years old.  Consistent with prior research age was an independent risk factor for retear with significant risk in patients > 70 y.o.