Lots of people from all walks of life can suffer from shoulder pain, and it’s one of the most common musculoskeletal problems we see in the clinic. You may have ongoing shoulder pain right now and are trying to find solutions. You might have gone through a shoulder injection or two which felt amazing for a few months the first time and maybe didn’t help at all the second time. You may even have been advised to go for shoulder surgery from a doctor or surgeon.
If you’re under 60 and have suffered from non-traumatic shoulder pain before, chances are you’ve been diagnosed as having rotator cuff tendinopathy, or shoulder impingement, or even shoulder bursitis. The fact of the matter is that they are essentially considered the same problem and are treated as such. The reasoning for the variety of diagnoses is due to the fact that studies have theorised that the “impingement”-type shoulder pain arises from an inflamed bursa or an inflamed rotator cuff tendon (or in some cases bony anatomy), causing either or both to swell up which in turn compresses the rotator cuff muscles and causes impingement and pain in certain activities – usually those involving overhead movements.
This has led to the use of shoulder arthroscopy surgery, or more specifically, subacromial decompression, and/or acromioplasty. This keyhole surgery commonly involves the removal of the inflamed bursa, removing some bone off the top of the shoulder, and any potential tissue which may lead to impingement of the shoulder. The surgeon may also repair any torn rotator cuff tendons.
In more recent times, shoulder impingement has been classified into broader terms such as subacromial pain syndrome, or rotator cuff-related shoulder pain. There are a lot of reasons for this, but in essence, there are numerous areas of the shoulder that could get grumpy and cause pain – muscles, ligaments, joints, and more. This makes it extremely difficult to truly identify the exact source of the pain, even with medical imaging. When you consider all this, it seems strange to only blame a bursa or a tendon for causing all this pain.
Before you make the decision, it’s definitely worth looking at all perspectives and considering the best option based on research and evidence.
So what does the research say?
There are some good quality literature reviews looking at surgery vs. sham/placebo surgery. To date, there is very limited evidence to support the benefits of subacromial decompression surgery. Any joint surgery usually does improve pain in the short term. However, this improvement never really lasts more than a year. In fact, studies comparing surgery to sham surgery showed no significant difference in pain and function from as early as 6 to 12 months!
There is also very limited evidence to support the benefits of surgery over conservative management and exercise, which is rather interesting considering most surgeons after surgery would recommend months of exercise and rehab anyway!
Elective surgery has its place, but when weighing up all the risks of surgery against the potential benefits, it makes more sense to consider it a last line of treatment.
Now this doesn’t mean that no one should ever have shoulder surgery – there is definitely a place for it, and it may even be the one thing that solves the pain. However when looking at the research for non-traumatic shoulder pain, surgery should almost never be the first line of treatment. If you’ve tried every other option including several months of structured rehab and nothing is working, there is always that option to go for surgery. Either way, some rehab is going to be involved to get you back up to speed. In the end it’s your choice to make, but by all means – try out some exercise first, and if you want some advice or help, see a Physio!
Written by Jed
Lähdeoja T, Karjalainen T, Jokihaara J, et al. Subacromial decompression surgery for adults with shoulder pain: a systematic review with meta-analysis. British Journal of Sports Medicine 2020;54:665-673.
Mitchell C, Adebajo A , Hay E , et al. Shoulder pain: diagnosis and management in primary care. BMJ 2005;331:1124–8.