Kaitlyn Parrotte, PT, DPT, OCS, CFMT edited by Fiona McMahon PT, DPT
Shoulder pain is a fairly common issue amongst adults, with up to 70% of us experiencing it in our lifetime and estimates of cost burden up to $7 billion a year for treatments of shoulder pain. Subacromial shoulder pain is what we call pain that is felt in the top and lateral (outside part of the shoulder). The pain originates from the subacromial space, which is a very small area between part of the shoulder blade called the acromion (“roof of the shoulder”), and the shoulder joint (the glenohumeral joint). In subacromial space, lies the rotator cuff tendons and the subacromial bursa (a fluid filled sack that helps minimize friction on these tendons). The pain from this area is typically caused by inflammation and/or tearing of the rotator cuff tendons, as they are pinched/rubbed against the underside of the acromion. Pain in this area can be aggravated by performing over head tasks, thing loading your carry on baggage into the overhead bin. There have been multiple research studies that have looked into the benefit of surgery for the treatment of subacromial shoulder pain. Today, we will be focusing on one article that looks at the effect of arthroscopic subacromial decompression (a common surgery for pain by removing tissue), as compared to a placebo surgery (no tissue actually removed), and no treatment. Here is a quick summary of the study: 313 patients were randomly assigned to treatment groups: 106 to decompression surgery, 103 to arthroscopy only, and 104 to no treatment. For the decompression surgery, surgeons removed soft tissue and other structures within the subacromial space, a nearby ligament, and removal of any bone spurs. For the arthroscopy, structures were inspected and irrigated, but nothing was removed or repaired. Following surgery, both groups (decompression and arthroscopy) received appropriate post-operative care, including follow-ups with the surgeons, as well as physical therapy. Those participants assigned to the no-treatment group attended one reassessment appointment with a shoulder specialist, 3 months after entering the study, but with no planned intervention. The pre- and post-test findings were mainly based on a functional shoulder measure. The findings in this study turned out to be very interesting, although perhaps not what the authors originally intended. Not because both surgical groups reported higher scores on the functional measure, as compared to the no-treatment group, which is something that one can expect when an intervention is appropriately applied. The main take home message from this study is not even that researchers reported participants in both surgical groups ended the study with similar outcomes. A major plot twist in this article is that both surgical groups were given physical therapy post-operatively. Remember, the group who received arthroscopy did not actually have any structures repaired or removed, yet this group made statistically significant gains after all intervention were completed, that matched, if not bested, the results of an actual surgical intervention. How could this occur? We must consider the common denominator – physical therapy! Physical therapy is the only thing that both groups had in common, so it is safe to assert that it likely played a significant role in the improvement of shoulder pain. If that isn’t convincing enough, let’s now focus on a research article that takes a closer look at the impact of physical therapy for patients with subacromial impingement syndrome. This article published in 2012 looked at a specific exercise routine vs generalized exercise for 102 patients in Sweden, who had already failed conservative treatments for their shoulder pain, and would likely become candidates for surgery due to their continued pain. Participants in both groups received a subacromial injection of corticosteroids two weeks prior to the commencement of any exercise. The control group received general exercises that including shoulder and neck movements and stretches. The experimental group was given six exercises to perform, which included eccentric strengthening of the rotator cuff, meaning these muscles were actively controlling resistance while lengthening, stabilizing exercises of the shoulder blade, and stretching of the back of the shoulder. After performing these exercises two times per day for up to 12 weeks, and attending one physical therapy session per week, these patients reported significant improvements in functional measures for the shoulder, as compared to the control group. The authors also reported that significantly fewer participants from the specific exercise group opted for surgery after the trial was over (20%), as compared to 63% from the control group. This study not only shows that physical therapy is beneficial for decreasing subacromial shoulder pain, but it also proves that when it is tailored specifically toward the needs of an individual condition or presentation, it can still be effective even after a person has failed conservative treatment. In summary, subacromial shoulder pain is a very common condition, that can successfully be treated with physical therapy, even if conservative treatments have previously failed to relieve symptoms. The emphasis must be on finding the correct intervention program that meets the needs of each individual patient. If you or someone you know is dealing with shoulder pain, whether it is new or old, you or they could benefit from a tailored physical therapy program. Here at Beyond Basics Physical Therapy, all of our therapists have extensive training and are experts in orthopedic and sports-related injuries, and will work one-on-one with you to develop a rehab program that helps you achieve your goals, so make an appointment today! Sources: 1. Cadogan A, Laslett M, Hing WA, McNair PJ, Coates MH. 2011. A prospective study of shoulder pain in primary care: prevalence of imaged pathology and response to guided diagnostic blocks. BMC Musculoskeltal Disorders, 12 (119). 2. Kulkarni R, Gibon J, Brownson P, et al. 2015. BESS/BOA Patient care pathways – subacromial shoulder pain. Shoulder & Elbow, 7 (2), 135-143. 3. Mesilin RJ, Sperling JW, Stitik TP. 2005. Persistent shoulder pain: epidemiology, pathophysiology, and diagnosis. Am J Orthop, 34 (12 Suppl), 5-9. 4. Beard DJ, Rees JL, Cook JA, et al. 2017. Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW): a multicentre, pragmatic, parallel group, placebo-controlled, three-group, randomised surgical trial. The Lancet, 17 (32457), doi: 10.1016/S0140-6736. 5. Holmgren T, Hallgren HB, Oberg B, et al. 2012. Effect of specific exercise on need for surgery in patients with subacromial impingement syndrome: a randomized controlled study. BMJ, 344 (787), doi: 10.1136//bmj.e787.