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No evidence of long-term benefits of arthroscopic acromioplasty in the treatment of shoulder impingement syndrome FIVE-YEAR RESULTS OF A RANDOMISED CONTROLLED TRIAL


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To report the five-year results of a randomised controlled trial examining the effectiveness of arthroscopic acromioplasty in the treatment of stage II shoulder impingement syndrome. A total of 140 patients were randomly divided into two groups: 1) supervised exercise programme (n = 70, exercise group); and 2) arthroscopic acromioplasty followed by a similar exercise programme (n = 70, combined treatment group). The main outcome measure was self-reported pain as measured on a visual analogue scale. At the five-year assessment a total of 109 patients were examined (52 in the exercise group and 57 in the combined treatment group). There was a significant decrease in mean self-reported pain on the VAS between baseline and the five-year follow-up in both the exercise group (from 6.5 (1 to 10) to 2.2 (0 to 8); p < 0.001) and the combined treatment group (from 6.4 (2 to 10) to 1.9 (0 to 8); p < 0.001). The same trend was seen in the secondary outcome measures (disability, working ability, pain at night, Shoulder Disability Questionnaire and reported painful days). An intention-to-treat analysis showed statistically significant improvements in both groups at five years compared with baseline. Further, improvement continued between the two- and five-year timepoints. No statistically significant differences were found in the patient-centred primary and secondary parameters between the two treatment groups. Differences in the patient-centred primary and secondary parameters between the two treatment groups were not statistically significant, suggesting that acromioplasty is not cost-effective. Structured exercise treatment seems to be the treatment of choice for shoulder impingement syndrome.
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VOL. 2, No. 7, JULY 2013 132
No evidence of long-term benefits of
arthroscopic acromioplasty in the treatment
of shoulder impingement syndrome
S. Ketola,
J. Lehtinen,
T. Rousi,
M. Nissinen,
H. Huhtala,
Y. T. Konttinen,
I. Arnala
From Kanta-Häme
Central Hospital,
S. Ketola, MD, Orthopaedic
Coxa Hospital for Joint
Replacement, Biokatu 6b, P.O.
Box 652, FI-33101 Tampere,
J. Lehtinen, MD, PhD,
Orthopaedic Surgeon
Hatanpää Hospital, PL 437, FI-
33101 Tampere, Finland.
T. Rousi, MD, Physiatrist
Suomen Terveystalo, Ahjonkatu
1, FI-05800 Hyvinkää, Finland.
M. Nissinen, MD, PhD,
Physiatrist, Assistant Professor
Helsinki University Central
Hospital, Rehabilitation Unit, PO
Box 100, FI-00029 HUS, Finland.
H. Huhtala, MSci,
University of Tampere, School of
Health Sciences, FI-33014
Tampere, Finland.
Y. T. Konttinen, MD, PhD,
Professor of Medicine
University of Helsinki and Helsinki
University Central Hospital,
Department of Medicine,
Biomedicum, PO Box 700, FI-
00029 HUS, Finland.
I. Arnala, MD, PhD, Adjunct
Professor, Orthopaedic Surgeon
Kanta-Häme Central Hospital,
Ahvenistontie 20, Hämeenlinna
FI-13530, Finland.
Correspondence should be sent
to Dr I. Arnala; e-mail:
Bone Joint Res 2013;2:132–9.
Received 12 February 2013;
Accepted after revision 14 June
To report the five-year results of a randomised controlled trial examining the effectiveness of
arthroscopic acromioplasty in the treatment of stage II shoulder impingement syndrome.
A total of 140 patients were randomly divided into two groups: 1) supervised exercise
programme (n = 70, exercise group); and 2) arthroscopic acromioplasty followed by a
similar exercise programme (n = 70, combined treatment group).
The main outcome measure was self-reported pain as measured on a visual analogue scale.
At the five-year assessment a total of 109 patients were examined (52 in the exercise group
and 57 in the combined treatment group). There was a significant decrease in mean self-
reported pain on the VAS between baseline and the five-year follow-up in both the exercise
group (from 6.5 (1 to 10) to 2.2 (0 to 8); p < 0.001) and the combined treatment group
(from 6.4 (2 to 10) to 1.9 (0 to 8); p < 0.001). The same trend was seen in the secondary
outcome measures (disability, working ability, pain at night, Shoulder Disability
Questionnaire and reported painful days). An intention-to-treat analysis showed statistically
significant improvements in both groups at five years compared with baseline. Further,
improvement continued between the two- and five-year timepoints. No statistically
significant differences were found in the patient-centred primary and secondary parameters
between the two treatment groups.
Differences in the patient-centred primary and secondary parameters between the two
treatment groups were not statistically significant, suggesting that acromioplasty is not
cost-effective. Structured exercise treatment seems to be the treatment of choice for
shoulder impingement syndrome.
Article focus
The effectiveness of acromioplasty in
shoulder impingement syndrome
Key messages
Structured exercise treatment is the treat-
ment of choice for shoulder impingement
Strengths and limitations of this
A randomised controlled trial
Results may in part reflect the natural
course of shoulder impingement syndrome
Shoulder pain is a common complaint,
sometimes described as the second most
common musculoskeletal disorder after
low back pain.1-4 Impingement is often
cited as the leading cause of pain in the
shoulder,5 which was initially thought to
arise from the mechanical friction of the
tendon under the acromion.6 However, fur-
ther studies and treatment trials have not
been able to demonstrate a pure mechani-
cal aetiology for this syndrome,7,8 and
therefore current treatment options remain
Freely available online
Keywords : Shoulder impingement, Syndrome, Operation, Physiotherapy, Arthroscopic, Acromioplasty
Impingement of the shoulder has a severe and long-
lasting effect on the patient, with costs of treatment and
absence from work causing economic consequences.
The syndrome is traditionally divided into three stages:
Stage I, oedema and haemorrhage; Stage II, fibrosis and
tendinitis; and Stage III, tears of the rotator cuff, biceps
ruptures and bone changes.17 The condition usually
begins gradually and then over time becomes continu-
ous.18 Its diagnosis is based on clinical examination,
which makes its nature somewhat imprecise. The first
mode of treatment is non-operative, involving rest, sub-
acromial corticosteroid injections,19 oral non-steroidal
anti-inflammatory drugs20 and physiotherapy.9,20-23
Although surgical treatment has not been conclusively
shown to be superior to conservative treatment,13- 16 , 24
arthroscopic acromioplasty is still a popular procedure
with a rising incidence over the last decade.25,26
Clear indications for different modes of treatment
based on randomised clinical trials have not yet been
defined. It seems that the expectations of both the sur-
geons and the patients and the availability of the
arthroscopic technology affect the demand.
We designed a randomised clinical trial to investigate
the eventual additional effect of arthroscopic decompres-
sion with acromioplasty on a supervised exercise pro-
gram.24 We now report the five-year results.
Patients and Methods
The study design was a prospective, controlled and ran-
domised trial. Patients were recruited from the area of
Kanta-Häme Health Care District (population 165 000)
between June 2001 and July 2004. The full exclusion and
inclusion criteria are provided in Table I. The eligibility of
the patients was examined at baseline by a physician (a
specialist in rehabilitation or orthopaedics). Impingement
was tested with Neer’s method17 by assessing whether
lidocain injected into the subacromial space relieved the
pain. All patients had a plain radiograph and MRI of the
symptomatic shoulder.27 The risks and benefits of both
treatments were discussed and the patients were also
given written information. Included patients were asked
to sign a written consent in which they voluntarily agreed
to comply with the randomised treatment protocol and
follow-up visits, with the right to withdraw at any time
without giving reason for it.
A total of 140 patients (52 men and 88 women) with a
mean age of 47.1 years (23 to 60) were recruited to the
study, which was approved by the Ethics Committee of
the Hospital District. Patients were randomly assigned to
the treatment groups using computer-generated num-
bers sealed in envelopes prepared by an independent
statistician not otherwise involved with the study.
Demographic data and disability-values and a struc-
tured Shoulder Disability Questionnaire (SDQ)28,29 were
collected at baseline. The SDQ contains common situa-
tions referring to the preceding 24 hours (yes/no/not
applicable (i.e. not occurred)). The score is calculated by
dividing the number of positive scores to the total num-
ber of applicable items subsequently multiplied by 100
(0 no disability, 100 all applicable items positive). All
patients had received various types of physiotherapy
including massage, heat, transcutaneous nerve stimula-
tion and exercises, but had not been treated by a special-
ised physician before entering the study.
The control visit assessment, including SDQ-score and
the clinical measurements, were performed by an inde-
pendent, blinded investigator (physiotherapist), not oth-
erwise involved in the study or rehabilitation, at three and
six months and at one, two and five years. The health-
related quality of life was measured at the five-year visit
using the 15D quality of life tool.30
Supervised exercise. Physiotherapeutic training was
based on home exercises, for which the patients
received individual guidance and general information
during an average of seven visits to an independent
The aim of the supervised exercise treatment was to
restore painless, normal mobility of the shoulder complex
and to increase the dynamic stability of the glenohumeral
joint and the scapula.31 Series of long painless movement
with repetition were undertaken with the aim of strength-
ening the tendons. Patients were instructed to do nine
different exercises at least four times a week, with three
courses of 30 to 40 repetitions. As the self-assessed ability
and strength improved, resistance was increased and rep-
etitions diminished. The progress was evaluated at con-
trol visits (mean of seven) and continued until the patient
and the therapist considered that the trainee was inde-
pendently able to maintain the practise level.
Combined treatment: surgery. One independent expe-
rienced orthopaedic surgeon performed all the
Tab l e I. Inclusion and exclusion criteria (NSAIDs, non-steroidal anti-
inflammatory drugs)
Inclusion criteria
Clinical symptoms of shoulder impingement syndrome
A positive Neer’s test
Symptom duration of at least three months
Attempts to treat with: rest, NSAIDs, subacromial corticosteroid injections
and regular physiotherapy
Age between 18 and 60 years
No previous operations on shoulder region
Willingness and capacity to comply with the treatment protocol and follow-
up visits
Exclusion criteria
Signs of glenohumeral instability
A penetrating rupture of the rotator cuff
Cervical radicular syndrome
Adhesive capsulitis
Neuropathy of the shoulder region
VOL. 2, No. 7, JULY 2013
arthroscopic decompressions under regional anaesthesia
at Kanta-Häme Central Hospital, Hämeenlinna, Finland.
Debridement and decompression were performed with a
shaver and/or a vaporisator. Acromioplasty was under-
taken with a burr drill (Arthroscope Karl Storz GmbH, Tut-
tlingen, Germany). A standard posterior portal was used
to analyse the structures of the glenohumeral joint and to
reach the subacromial space. An anterolateral portal was
used to perform debridement and decompression. The
range of movement was tested under arthroscopic visual-
isation to check for any local impingement.
The use of a collar cuff sling was recommended for one
week, after which mobilisation was allowed with free
active movements, starting with pendular motion. In the
rehabilitation period patients in the combined treatment
group received similar training instructions from a phys-
iotherapist as were provided for the exercise group with
the same kind of follow-up schedule. The training pro-
gramme was individually planned and progressive. It
started progressing once the post-operative pain had
started to diminish. Like in the supervised exercise treat-
ment group, the progress was evaluated at the visits to
the physiotherapist (mean of six visits).
Follow-up. At five years one trained independent phys-
iotherapist, who had not been involved with the
patients before evaluation and who was blinded to the
mode of treatment, performed all standardised assess-
ments. Patients were instructed not to indicate their
treatment group and they wore a T-shirt to cover even-
tual operation scars.
Outcome measures. Self-reported shoulder pain, as the
primary outcome measure, was assessed on a visual ana-
logue scale (VAS) ranging from 0 (no pain) to 10 (extreme
pain). Secondary outcome measures included disability
(measured on a VAS from 0 (no disability) to 10 (total dis-
ability)), working ability (VAS from 0 (totally unable to
work) to 10 (no restriction on work)), pain at night (VAS
from 0 (no pain) to 10 (extreme pain)), SDQ score, num-
ber of painful days during the previous three months and
the proportion of pain-free patients (defined as a VAS for
pain ≤ 3). The health related quality of life was measured
at the five-year visit using the 15-D tool and compared
with the age-adjusted population values.30
Statistical analysis. Power calculations were performed
based on the use of self-reported pain (VAS) as the pri-
mary outcome measure. Using 1.5 (SD 2.5) as a clinically
important change,32 the sample size was estimated to
45 patients per group, if 5% type I (α) and 20% type II (β)
errors were allowed. As the standard deviation of the out-
come measure was only a rough estimate, a total of
70 patients were included in both groups.
Statistical analyses were performed using IBM SPSS
Statistics for Windows v19.0 (IBM Corp., Armonk, New
York). Descriptive statistics are presented as percent-
ages, frequencies, and means. The independent sam-
ples t-test was used for group comparisons, paired
samples t-test for comparisons within groups over time
and the chi-squared test for equal proportions of pain-
free patients between groups. A p-value < 0.05 was con-
sidered to represent statistical significance.
The study groups did not differ at baseline in any pre-
operative measure (Table II). During the follow-up
between two and five years, a total of four patients in the
exercise group had undergone acromioplasty and one
patient had undergone operation of a rotator cuff rup-
ture. The mean time after randomisation until these five
operations were performed was 2.9 years (2.6 to 3.3).
Additionally, a total of 12 patients originally allocated to
the combined treatment group refused operation; one of
whom went on to undergo surgery at a follow-up of
2.6 years. The total number of operated patients in the
exercise group was 18. All these patients were invited to
and attended the five-year control visit. The follow-up
results were analysed using an intention-to-treat
approach, but the outcome is also described based on the
actual treatment using a per protocol approach.
The five-year follow-up was attended by 109 (77.9%) of
the original 140 patients recruited; 52 patients (74.3%) in
the exercise group and 57 (81.4%) in the combined
group. A statistically significant decrease in the mean self-
reported pain was observed from baseline to the five-year
follow-up in both groups: from 6.5 (1 to 10) to 2.2 (0 to 8)
in the exercise group and from 6.4 (2 to 10) to 1.9 (0 to 8)
in the combined treatment group (both p < 0.001, t-test).
There was no difference in self-reported pain between the
groups at the five-year follow-up (p = 0.44, independent-
samples t-test).
At five years, there was no statistically significant differ-
ence between the two groups in terms of self-reported
disability (p = 0.57), working ability (p = 0.41), night pain
(p = 0.95) or SDQ (p = 0.33, independent-samples t-tests)
(Table II). The proportion of pain-free patients at two
years was similar in the two groups, with 64% (42 of 66)
of the exercise group and 65% (44 of 68) of the combined
treatment group pain-free (p = 0.89, chi-squared test).
These proportions increased to 77% (40 of 52) of the
exercise group and 73% (43 of 57) of the combined treat-
ment group at five years (p = 0.86, chi-squared test)
(Table II). Of the 109 patients who attended the five-year
follow-up, 39 (36%) reported that they had had similar
symptoms or complaints in the contralateral shoulder:
18 (35%) in the exercise group (35%) and 21 (37%) in the
combined treatment group.
The 15D quality of life index was analysed in an inten-
tion-to-treat setting. Figure 1 displays the mean scores for
each parameter for the two groups and also the age-
adjusted general population.30 The groups had similar
15D values for total score (p = 0.82) and also by each
domain (mobility, p = 0.13; vision, p = 0.91; hearing,
p = 0.95; breathing, p = 0.67; sleeping, p = 0.81; eating,
p = 0.30; speech, p = 0.95; elimination, p = 0.01; usual
activities, p = 0.49; mental function, p = 0.45; discomfort
and symptoms, p = 0.81; depression, p = 0.99; distress,
p = 0.57; vitality, p = 0.45; and sexual activity, p = 0.61; all
independent samples Mann–Whitney U test). In compar-
ison with the age-adjusted general population the
Table II. Results in the intention-to treat analysis (CI, confidence inter val)
Mean outcome (range)*Exercise Combined treatment Mean difference (99% CI) p-value
Number of patients
At baseline (n = 140) 70 70
At two years (n = 134) 66 68
At five years (n = 109) 52 57
Self-reported pain VAS
Baseline 6.5 (1 to 10) 6.4 (2 to 10) -0.1 (-1.01 to 0.77) 0.73
Two years 2.9 (0 to 9) 2.5 (0 to 10) -0.4 (-1.60 to 0.78) 0.37
Five years 2.2 (0 to 8) 1.9 (0 to 8) -0.3 (-1.54 to 0.84) 0.44
Mean change from baseline
At two years -3.7 -3.9 -0.2 (-1.61 to 1.14) 0.65
At five years -4.1 -4.7 -0.6 (-2.13 to 1.01) 0.35
p-value (baseline vs five-year) < 0.001< 0.001
Disability VAS
Baseline 6.5 (2 to 10) 6.2 (1 to 10) -0.3 (-1.13 to 0.75) 0.23
Two years 2.6 (0 to 9) 2.0 (0 to 10) -0.6 (-1.81 to 0.62) 0.21
Five years 1.8 (0 to 9) 1.5 (0 to 8) -0.3 (-1.45 to 0.93) 0.57
Mean change from baseline
At two years -3.8 -4.2 -0.4 (-1.76 to 1.00) 0.47
At five years -4.4 -4.8 -0.4 (-2.07 to 1.16) 0.46
Working ability VAS
Baseline 5.9 (0 to 9) 5.7 (0 to 9) -0.2 (-1.42 to 0.85) 0.78
Two years 8.0 (1 to 10) 8.0 (0 to 10) 0.0 (-0.82 to 0.85) 0.96
Five years 7.5 (2 to 10) 7.8 (1 to 10) +0.3 (-0.66 to 1.27) 0.41
Mean change from baseline
At two years +2.0 +2.3 +0.3 (-0.93 to 1.52) 0.47
At five years +1.6 +2.2 +0.6 (-0.81 to 2.18) 0.23
Night pain VAS
Baseline 6.4 (0 to 10) 6.2 (0 to 10) -0.2 (-1.46 to 0.93) 0.60
Two years 2.6 (0 to 9) 2.0 (0 to 8) -0.6 (-1.95 to 0.65) 0.19
Five years 1.7 (0 to 8) 1.7 (0 to 9) 0.0 (-1.19 to 1.25) 0.95
Mean change from baseline
At two years -3.8 -4.2 -0.4 (-2.00 to 1.17) 0.51
At five years -4.8 -4.8 0.0 (-1.75 to 1.73) 0.99
SDQ score
Baseline 82.5 (0 to 100) 78.1 (0 to 100) -4.4 (-14.4 to 4.47) 0.21
Two years 32.8 (0 to 100) 24.2 (0 to 100) -8.6 (-23.34 to 6.10) 0.13
Five years 22.2 (0 to 100) 16.9 (0 to 100) -5.3 (-19.54 to 8.90) 0.33
Mean change from baseline
At two years -50.0 -53.2 -3.2 (-19.11 to 12.75) 0.6
At five years -61.7 -60.4 +1.3 (-15.74 to 18.34) 0.84
Reported painful days in
preceding three months (n)
Baseline 73.8 (5 to 90) 70.1 (0 to 90) -3.7 (-16.28 to 8.86) 0.44
Two years 19.7 (0 to 90) 13.9 (0 to 90) -5.8 (-18.16 to 6.52) 0.22
Five years 11.8 (0 to 90) 12.2 (0 to 90) +0.4 (-12.52 to 13.32) 0.94
Mean change from baseline
At two years -53.3 -55.0 -1.7 (-19.68 to 16.22) 0.80
At five years -59.4 -60.8 -1.4 (-20.57 to 17.83) 0.85
Patients pain-free (%)
Baseline 4% (3 of 70) 11% (8 of 70) +7% (-0.197 to 0.055) 0.21§
Two years 64% (42 of 66) 65% (44 of 68) +1% (-0.224 to 0.203) 0.89§
Five years 77% (40 of 52) 75% (43 of 57) -2% (-0.219 to 0.195) 0.86§
* VAS, visual analogue scale: pain/night pain (0 = no pain, 10 = extreme pain), disability (0 = no disability, 10 = total disability), working ability
(0 = tot ally unable to work , 10 = no restriction on wor k); SD Q, Sho ulder Disability Quest ionnaire (from 0 to 100, wit h 0 denoting no functional
† independent samples t-test, unless otherwise stated
‡ paired samples t-test, unless otherwise stated
§ chi-squared test
VOL. 2, No. 7, JULY 2013
exercise treatment group had lower values in the ‘usual
activities’ and ‘discomfort’ dimensions (p = 0.040 and
p = 0.037, respectively), and the combined treatment
group had lower values in the ‘mobility’, ‘sleeping’ and
‘discomfort’ parameters (p < 0.001, p = 0.049 and
p = 0.028, respectively; all independent samples Mann–
Whitney U test). All these differences exceeded the mini-
mally clinically important difference (MCID) of between
0.02 and 0.0333 (Fig. 1).
Of the whole group, 16 patients were retired at five
years (one already at enrolment). In the combined treat-
ment group five were retired, one due to old age and four
on a disability/unemployment pension unrelated to
shoulder symptoms. In the exercise group 11 patients
were retired, three due to old age and eight were on a dis-
ability/unemployment pension, two of which were due
to shoulder-related reasons. Two additional patients were
part-time retired, one due to shoulder-related reasons
(exercise group).
Seven patients in each group reported that changes
had been made in their working arrangements due to
shoulder-related reasons.
The current study suggests that treatment with
arthroscopic decompression combined with structured
exercise treatment did not provide better results at five
years compared with structured exercise alone, when
assessed by self-reported pain. The same pattern was
seen in the secondary outcome measures of disability,
pain at night, SDQ score, number of painful days and the
proportion of pain-free patients.
The improvements seen in both groups at the two-year
follow-up continued to the five-year follow-up, resulting
in highly significant improvements compared with the
baseline values. However, there were no statistically
significant differences between the groups. These five-
year results indicate that arthroscopic decompression
does not have any additional effect on conservative struc-
tured exercise. Furthermore, based on the current results,
arthroscopic decompression does not have any
prophylactic effect from a five-year perspective because
the non-decompressed conservatively treated patients
did as well as those who underwent operative release of
the impingement.
Some parameters of the 15D quality of life index were
slightly worse in patients treated for shoulder impinge-
ment than in the age-adjusted general population, but
there were no differences between the treatment groups
in these health-related quality of life parameters.
There have been randomised controlled trials compar-
ing conservative and operative treatment of shoulder
impingement syndrome13, 14 and others have investigated
the effect of the treatment on disability and working
capacity.15,16 In these earlier studies, failure to respond to
regular physiotherapy and other conservative treatment
was used as an inclusion criterion. In contrast, the present
study aimed to examine whether operative treatment
15D index
Discomfort &
Combined treatment
Exercise treatment
Fig. 1
Graph showing the 15D Quality of Life index in the combined and exercise treatment groups and in comparison with age-adjusted standard pop-
ulation at five years.
provided any additional value to a conservative struc-
tured exercise treatment. At all follow-up visits the
patients were evaluated by a blinded, independent asses-
sor, thus minimising any bias. Selection and drop-out
biases were minor as all eligible consecutive 140 patients
volunteered to the study and the drop-out rate even at
five years was relatively small (six of 140 at two years and
31 of 140 at five years).
As the study was conducted in an ordinary provincial
hospital setting, not in a highly specialised shoulder cen-
tre, the external validity is relatively good. All operations
were performed by one experienced orthopaedic sur-
geon and without any significant surgical complications.
Although it concerns patients’ health and their decision,
in reality patients do not always follow the given
guidance. The similarity of the groups at baseline con-
firms a successful randomisation. Therefore, the adher-
ence to the treatment was probably rather similar in both
study groups.
The diagnosis of the impingement syndrome requires a
thorough patient history and a careful clinical examina-
tion to exclude other conditions that may mimic impinge-
ment. All patients were examined also with MRI at
baseline, in order to exclude conditions such as penetrat-
ing ruptures of the rotator cuff.
The age limits for inclusion were set at 18 and 60 years
in conformity with previous studies.13 -1 6 In patients aged
< 18 years, glenohumeral instability is the leading cause
of shoulder problems.34 However, our study included
only four patients aged < 30 years. The frequency of rota-
tor cuff tears is higher in patients aged > 60 years,35-37
hence their exclusion from our study.
Luyckx et al38 described 166 patients who underwent
arthroscopic subacromial decompression, and reported a
mean time between operation and full activity of
11.1 weeks (with a minimum of one week). In the present
study, patients in the combined treatment group reported
a mean of 28.1 days leave of absence due to shoulder-
related reasons at the month follow-up visit and additional
4.6 days between the three- and six-month follow-up visits
due to surgical procedure (Table III). The use of sick leave
was minimal between the two- and five-year follow-up
visits. Values were slightly higher in the exercise group,
probably due to shifts in the group and operations per-
formed between the two- and five-year visits. The differ-
ence in the total number of sick leave days was not
statistically significant between the study groups
(p = 0.11), but still almost double in the combined treat-
ment group, which raises the overall health care costs.
Use of descriptive data in an ad hoc per protocol ana-
lysis (43 patients in the exercise group and 43 patients in
the combined treatment group) produced only slightly
better results (Table IV) than the intention-to-treat ana-
lysis (Table II). There were no statistically significant dif-
ferences between the groups in the per protocol
The reasons for the rising incidence of arthroscopic
acromioplasty are complex. This trend may be driven by
patient, surgeon, technology, society and/or employer
related reasons. At present, expenses and best evidence
must also be taken into consideration. Based on our
Table III. Leave of absence from work due to shoulder-related symptoms during the
three months preceding the control visit, except at five years when the year preceding
the visit was used
Mean absence from work (days) (range)
Control point Exercise Combined treatment p-value*
3 months 5.3 (0 to 60) 28.1 (0 to 90) < 0.001
6 months 2.4 (0 to 65) 4.6 (0 to 90) 0.45
12 months 4.2 (0 to 58) 4.4 (0 to 90) 0.94
2 years 3.8 (0 to 65) 0.1 (0 to 4) 0.03
5 years 3.2 (0 to 110) 0.4 (0 to 10) 0.22
Tot a l 16.5 31. 2 0.11
* t-test
Tab l e IV. Results in the per protocol analysis at five years (SDQ,
Shoulder Disability Questionnaire)
Mean outcome
Full exercise
treatment group
(n = 43)
Full combined
treatment group
(n = 43)
Self-reported pain
2 years 2.5 2.4
5 years 1.8 1.6
2 years 2.1 2.0
5 years 1.3 1.2
Working ability
2 years 8.5 8.0
5 years 8.0 7.8
Night pain
2 years 2.1 2.1
5 years 1.2 1.3
SDQ score
2 years 26.9 22.1
5 years 16.7 12.0
Painful days
2 years 13.6 13.9
5 years 8.3 7.8
VOL. 2, No. 7, JULY 2013
two-year results we concluded that acromioplasty is not
cost-effective.24 Structured exercise treatment should be
the treatment of choice for shoulder impingement syn-
drome. Operative treatment should be offered with dis-
cernment. In 2010 the Finnish National Institute for
Health and Welfare reported that the combined inci-
dence of open and arthroscopic acromioplasties was
91.6/100 000 in Finland.39 In the New York area the inci-
dence was 101.9/100 000 in 2006 and has risen vastly in
the previous decade.25 The indications for arthroscopic
acromioplasty should also be thoroughly discussed. We
believe that the natural course of the disease should be
better defined to improve the judgement of different
treatment options.
The indications for arthroscopic acromioplasty in the
treatment of shoulder impingement syndrome should be
reconsidered. Based on our results, it seems that the mere
presence of an uncomplicated shoulder impingement
syndrome is not an indication for arthroscopic acromio-
plasty per se, as conservative treatment with a structured
exercise program provides as good results at five years at
a lower cost.
Conclusions. The additional effect of acromioplasty on
top of structured exercise is not significant in the treat-
ment of shoulder impingement syndrome when evalu-
ated at two and five years. Approximately 75% of patients
recover well and the rest continue to have discomfort
despite the treatment. The effects of the arthroscopic
acromioplasty may have been overestimated due to
regression to the mean and the natural long-term course
of the shoulder impingement syndrome.
The authors would like to thank A-M. Lampela, Physiotherapist, for assistance in examining
the patients and Professor H. Sintonen for providing the 15D age-adjusted general popula-
tion data for comparison.
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Funding statement:
None declared
Author contributions:
S. Ketola: Planning of the study (overall planning), Substantive intellectual contribu-
tion, Seeking permits from the ethical committee, Seeking permits from the hospitals,
Recruitment of the patients, Organisation of the study, Collection and organisation of
the data, Statistical analysis, Literature review, Writing the draft, Critical commenting
and improvement of the manuscript
J. Lehtinen: Recruitment of the patients, Organisation of the study, Thesis supervision,
Clinical analysis of the data, Literature review, Writing the draft, Critical commenting
and improvement of the manuscript
T. Rousi: Planning of the study (overall and especially physiotherapeutic aspects), Seek-
ing permits from the ethical committee, Seeking permits from the hospitals, Clinical
analysis of the data, Critical commenting and improvement of the manuscript
M. Nissinen: Planning of the study, Recruitment of the patients, Seeking permits from
the hospitals, Critical commenting and improvement of the manuscript
H. Huhtala: Statistical analysis, Critical commenting and impro vement of the manuscript
Y. T. Konttinen: Substantive intellectual contribution, Clinical analysis of the data, Criti-
cal commenting and improvement of the manuscript
I. Arnala: Planning of the study (overall and especially operative aspects), Seeking per-
mits from the hospitals, Organisation of the study, Thesis supervision, Clinical analysis
of the data, Critical commenting an d improvement of the manuscript
ICMJE Conflict of Interest:
None declared
©2013 The British Editorial Society of Bone & Joint Surgery. This is an open-access arti-
cle distributed under the terms of the Creative Commons Attributions licence, which per-
mits unrestricted use, distribution, and reproduction in any medium, but not for
commercial gain, provided the original author and source are credited.
... The underlying mechanism for rotator cuff abnormalities has been thought to include intrinsic and extrinsic factors. Whereas SAI has long been accepted as the major extrinsic factor for rotator cuff tendinopathy [20], some studies have demonstrated that surgical decompression has no beneficial effects in patients with SAI in the short-term period compared with exercise therapy or placebo surgery for patients with SAI [38][39][40][41][42][43][44][45][46]. Regarding long-term outcome, Ketola et al. reported no long-term beneficial effect of subacromial decompression on pain compared with placebo and exercise in the treatment of patients with rotator cuff tendinopathy at least 10 years after the treatment [47]. ...
Full-text available
Background Subacromial impingement (SAI) may be a cause of age-related rotator cuff abnormalities; therefore, the purpose of this study was to compare SAI characteristics between younger and older adults. In addition to the fact that thickened supraspinatus tendon (SST) indicates tendon abnormalities, SAI characteristics have been recognized as follows: greater SST thickness, reduced acromiohumeral distance (AHD), greater reduction of AHD (∆AHD) with arm elevation, and a higher percentage of SST within AHD (i.e., occupation ratio: OcAHD). Furthermore, we investigated the relationships between SST thickness and AHD, as well as SST thickness and ∆AHD to clarify the effect of SAI on rotator cuff abnormalities. Methods Healthy younger ( n = 18, 21–24-year-old) and older ( n = 27, 45–80-year-old) adults without any shoulder symptoms participated in this study. We measured their SST thickness and AHD at rest and at arm elevation (30° and 60°) in the scapular plane using ultrasound, and calculated ∆AHD as the relative change expressed as a percentage of the baseline. OcAHD was expressed as the ratio of SST thickness at rest to AHD at rest and in elevated positions. Results The older subjects had approximately one mm thicker SST ( P = 0.003, 95% Confidence interval [CI] = 0.410 to 1.895) and approximately 1.0 to 1.3 mm greater AHD than the younger subjects ( P = 0.011, 95%CI = 0.284 to 2.068 at rest; P = 0.037, 95%CI = 0.082 to 2.609 for 30° of arm elevation; P = 0.032, 95%CI = 0.120 to 2.458 for 60° of arm elevation). However, there were no differences in ΔAHD and OcAHD between the groups. Conclusion This study demonstrated that, compared with the younger subjects, the older subjects showed thicker supraspinatus tendon but no other SAI characteristics including decreases in AHD and increases in OcAHD. Thus, this study suggests that older subjects showed age-related SST abnormalities without SAI, although the magnitude of the differences in SST thickness is notably small and the clinical significance of this difference is unclear.
... These findings mirror closely with the results of our ASD vs. ET comparison (Fig. 2). Two of these trials have also compared the RTW outcomes between ASD and exercise therapy at a longer, 5-year follow-up, finding no differences in self-reported work status or working ability [17,19]. In an extended 10-year follow-up of the latter trial, there was no difference in return to work, sick leave days nor retirement rates due to shoulder problems between the groups [18]. ...
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Background Arthroscopic subacromial decompression is one of the most commonly performed shoulder surgeries in the world. It is performed to treat patients with suspected shoulder impingement syndrome, i.e., subacromial pain syndrome. Only few studies have specifically assessed return-to-work rates after subacromial decompression surgery. All existing evidence comes from open, unblinded study designs and this lack of blinding introduces the potential for bias. We assessed return to work and its predictors in patients with shoulder impingement syndrome in a secondary analysis of a placebo-surgery controlled trial. Methods One hundred eighty-four patients in a randomised trial had undergone arthroscopic subacromial decompression ( n = 57), diagnostic arthroscopy, a placebo surgical intervention, ( n = 59), or exercise therapy ( n = 68). We assessed return to work, defined as having returned to work for at least two follow-up visits by the primary 24-month time point, work status at 24 and 60 months, and trajectories of return to work per follow-up time point. Patients and outcome assessors were blinded to the assignment regarding the arthroscopic subacromial decompression vs. diagnostic arthroscopy comparison. We assessed the treatment effect on the full analysis set as the difference between the groups in return-to-work rates and work status at 24 months and at 60 months using Chi-square test and the predictors of return to work with logistic regression analysis. Results There was no difference in the trajectories of return to work between the study groups. By 24 months, 50 of 57 patients (88%) had returned to work in the arthroscopic subacromial decompression group, while the respective figures were 52 of 59 (88%) in the diagnostic arthroscopy group and 61 of 68 (90%) in the exercise therapy group. No clinically relevant predictors of return to work were found. The proportion of patients at work was 80% (147/184) at 24 months and 73% (124/184) at 60 months, with no difference between the treatment groups ( p -values 0.842 and 0.943, respectively). Conclusions Arthroscopic subacromial decompression provided no benefit over diagnostic arthroscopy or exercise therapy on return to work in patients with shoulder impingement syndrome. We did not find clinically relevant predictors of return to work either. Trial registration identifier NCT00428870 .
... Today, if a rupture of any sort is revealed, it is not uncommon for practitioners and patients to warrant a referral to an orthopedic clinic, instead of starting graded exercise, which is consensus for the physiotherapy treatment (Klintberg et al., 2015). For this group of patients surgical intervention is unnecessary and also correlated to significantly greater costs for the society than physiotherapy (Ketola et al., 2013). In concert with previous studies, the present study showed that US findings in terms of diagnosing patients with non-traumatic shoulder pain should not be used as the only diagnostic tool (Guzowski et al., 2019;Moosmayer, Smith, Tariq, and Larmo, 2009). ...
Full-text available
Background: Subacromial pain syndrome is a common musculoskeletal shoulder problem. The accuracy of clinical tests is low and techniques such as ultrasound and magnetic resonance imaging have been added to set up a diagnosis. Previous researchers have usually only examined the symptomatic shoulder. However, there might be similar findings in the asymptomatic shoulder. Objective: The aim of the present study was to investigate the prevalence of structural abnormalities of both shoulders in patients with clinically diagnosed unilateral subacromial pain syndrome using diagnostic ultrasound. Methods: Bilateral ultrasound examinations were performed in 115 consecutive patients, 54 men and 61 women. The patients were recruited from primary care centers in the area of Stockholm, Sweden. Results: Abnormal ultrasound findings were found in both shoulders and increased with age (p = .0004). Bursitis was the most common ultrasound finding and significantly more prevalent in the symptomatic shoulder compared to the asymptomatic shoulder (90%:74%; p = .0021), though 73% of the bursitis were bilateral. Supraspinatus is the most vulnerable tendon of the rotator cuff in both shoulders. In terms of partial-thickness tears and tendinosis, the tendon was affected more commonly in the symptomatic shoulder compared to the asymptomatic shoulder (30%:14%: 14%; p = .0026) and (24%:10%; p = .0054), respectively, but for calcification no significant difference between the shoulders was found (18%:12%; 0.1988). Conclusion: Ultrasound detected shoulder abnormalities were present in both symptomatic and asymptomatic shoulders. Bursitis and partial-thickness tears were more common in the affected shoulder when compared to the unaffected shoulder. Ultrasound as well as clinical examination findings and patient´s history should be taken into consideration when diagnosing patients with subacromial pain syndrome.
Background: The study investigated the current epidemiologic and etiologic trends of shoulder pain over the past 10 years in South Korea.Current Concepts: From 2011 to 2020, nationwide health statistics data of the following diseases and soft tissue damage codes related to shoulder pain were extracted from the Healthcare Bigdata Hub—M75, S43, and S46. The annual changes in total medical cost and the number of patients with the three codes were extracted. The crude and age-standardized prevalence rates, and the annual percentage change were analyzed to characterize trends in prevalence rates over time. Changes in the proportion of medical cost by age, hospital type, and outpatient/inpatient distribution were also analyzed. Among the three codes, a significant increase in total medical cost, crude and age-standardized prevalence was observed only for the code M75. Additionally, in the distribution of total medical cost for the code M75 by age, the increase in the number of patients of the age group of 60 to 69 years was remarkable. The total medical cost gradually decreased at the clinic level and showed a remarkably increasing trend at the hospital level. This pattern is consistent with those of rotator cuff disease (M751), a representative disease of shoulder lesions.Discussion and Conclusion: The age of patients with shoulder pain appears to be increasing. Considering this trend of change in health statistics on shoulder pain in Korea, socioeconomic support and improvement of health policy regarding the distribution of medical expenses and resources for shoulder pain will be more necessary in the future.
Purpose The effect of arthroscopic subacromial decompression for impingement syndrome is still under debate. The purpose of this study was to evaluate short-term and long-term effects of arthroscopic decompression in patients with subacromial impingement. Methods A systematic literature search was performed in Pubmed, Embase, Scopus, Cochrane Library, and through March 2021 to identify randomized controlled trials (RCTs) that evaluated the clinical effects of arthroscopic decompression versus placebo surgery or exercise therapy for patients with subacromial impingement. Outcomes were analyzed on an intention-to-treat basis with random-effects models. Results Nine RCTs were included in the meta-analysis. The pooled analysis showed that arthroscopic decompression was associated with significantly better function improvement at 24-36 months and ≥ 60 months (24-36 months: SMD: 0.29, 95% CI: 0.10 to 0.48, P = 0.002; ≥ 60 months: SMD, 0.65, 95% CI, 0.20 to 1.09, P=0.004) compared with control group. Moreover, the effect size of function improvement ≥ 60 months exceeded the minimum clinically important difference (MCID). Additionally, sensitivity analysis indicated that compared with either exercise therapy or placebo surgery, arthroscopic decompression was associated with significantly better function improvement ≥ 60 months follow-up. However, there was no significant difference regarding pain relief at 6 months, 12 months, 24-36 months, ≥ 60 months, and function improvement at 6 months, 12 months for arthroscopic decompression compared with control group. Conclusion After ≥ 60 months of follow-up, arthroscopic decompression in patients with subacromial impingement appears to render better function results than exercise therapy and placebo surgery. Level of Evidence I, systematic review and meta-analysis of level I studies.
Chronic joint pain (>3 months) affects 63 million of Americans with 18.7 million reported shoulder (glenohumeral) joint pain, and 11.4 million reported wrist (radiocarpal) joint pain. Osteoarthritis (OA) is the most common cause of joint pain. With an aging population, the prevalence of joint pain is expected to rise. Mild to moderate symptoms can be managed with pharmacologic and physical therapy. For patients with moderate to advanced pain and disabilities, clinicians usually resort to more invasive therapy (injection or surgery). Various shoulder injections are available but the efficacy decreases with advanced disease when shoulder arthroplasty is usually considered. Unlike the hip and knee arthroplasties, the outcome of shoulder arthroplasty is not as promising and the risk of post-arthroplasty persistent pain is up to 22%.This chapter discussed in details the innervation of shoulder and the pertinent image-discernable landmarks that can be adopted for shoulder denervation.KeywordsSuprascapular nerveAxillary nerveLateral pectoral nerveSubscapular nerveRotator cuff tendinopathyDegenerative tears and impingementGlenohumeral and acromioclavicular joint osteoarthritisAdhesive capsulitisLabral tears
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Background: In recent years, the research on subacromial impingement syndrome (SIS) has gradually increased. Although the research directions are diverse, the overall research status and trend are not clear. Objective: The aim of our study was to use bibliometric analysis to identify the trends in SIS-related research and to analyze the most highly cited scientific publications on SIS. Methods: All data were retrieved from the Web of Science Core Collection database, and the year of publications, countries, journals, institutions and total number of citations were extracted and analyzed. The results related to countries, institutions and keywords were then analyzed using VOSviewer software and bibliometrics online analysis platform. And, we also identified the 100 most cited articles on SIS. Results: A total of 548 articles related to AIS were identified. The frequency of publication on SIS has increased substantially over time. Among all countries, Turkey has contributed the most publications on SIS (n=118). The institution with the most articles was Istanbul University (n=17). Journal of Shoulder and Elbow Surgery topped the list of journals and has published 19 SIS-related publications. The hotspot of research changed from the former arthroscopic surgery to physical therapy and rehabilitation. Conclusion: The scientific research on SIS has rapidly expanded in recent years. This study represents the first bibliometric analysis of SIS, gives us a systematic and comprehensive summary into the development of SIS.
Full-text available
Objective To quantify and describe effect size distributions from exercise therapies across a range of tendinopathies and outcome domains to inform future research and clinical practice. Design An extensive search of the literature with meta-analysis exploring moderating effects and context specific small, medium, and large thresholds. Eligibility criteria Randomised and quasi-randomised controlled trials involving any persons with a diagnosis of rotator cuff, lateral elbow, patellar, Achilles or gluteal tendinopathy of any severity or duration. Methods Standardised mean difference (SMDpre) effect sizes were used with Bayesian hierarchical meta-analysis and meta-regression models to calculate the 0.25-(small), 0.5-(medium), and 0.75-quantiles (large) and compare pooled means across potential moderators. Results Data were analysed from 114 studies (171 treatment arms 4104 participants). SMDpre effect sizes and credible intervals (CrI) across all tendinopathies and outcome domains demonstrated sizeable values for small (0.34 [95%CrI:0.31-0.37]), medium (0.73 [95%CrI:0.70-0.77]), and large (1.21 [95%CrI:1.17-1.27]) thresholds. Values were similar across tendinopathies but varied substantially across outcome domains with greater threshold values obtained for self-reported measures of pain, disability and function (small~0.6, medium~1.0, large~1.6), and the lowest values obtained for quality of life and objective measures of physical function (small~0.15, medium~0.4, large~0.70). Potential moderating effects of assessment duration, exercise supervision and symptom duration were also identified, with greater pooled mean effect sizes estimated for longer assessment durations, supervised therapies, and studies comprising patients with shorter symptom durations. Conclusion Effect sizes vary for different outcomes but are similar across tendinopathies, with research and clinical outcomes needing to be judged accordingly. Mean treatment effects are expected to be influenced by a range of factors with the most consistent evidence obtained for assessment duration and exercise supervision. The outcomes of new interventions should be assessed against domain-and time-specific effect sizes to be correctly interpreted. Threshold values presented here should be used to guide interpretation.
Background Shoulder pain is lacking a contemporary comprehensive overview article that summarizes key aspects of the presentation. Objective To provide a contemporary summary of the literature on shoulder pain, including: epidemiology, cost-of-illness, common diagnoses, common treatments, and prognosis. Methods PubMed, CINAHL and Google Scholar were searched using search terms including: shoulder pain, prevalence, epidemiology, diagnosis, risk factors, prognosis, surgery and conservative care. Information from the highest level of evidence available was synthesized and summarized. Results Shoulder pain is the third most common musculoskeletal complaint and several cost of illness studies suggest it is of significance. Common diagnoses can be categorised on the anatomic region such as ‘intra-articular’, ‘anterior shoulder’ and ‘subacromial’. Despite surgery rates increasing in some areas, multiple systematic reviews suggest there is no difference in pain and disability outcomes between surgical interventions and conservative approaches. Several studies have revealed that only 50% of all new cases of shoulder pain completely recovery after six months, and 60% after 12 months. Conclusion Shoulder pain is a relatively common musculoskeletal complaint and costs associated appear reasonably high. Practitioners need to be aware of overlap with diagnostic terms, the equivalence of available interventions, and that shoulder pain conditions may not be self-limiting.
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The incidence of arthroscopic subacromial decompression has been increasing over the last few years. Little is known about the duration of sick leave after such a procedure. The aim of this study was to determine the time till return to full duty and to explore the various influencing factors. We retrospectively evaluated a group of 166 patients who consecutively underwent arthroscopic subacromial decompression for subacromial impingement syndrome. One hundred patients were professionally active at the time of surgery; the mean duration till return to full duty was 11.1 weeks. Self-employed workers had the shortest sick leave period (median time of 1 week). No statistically significant difference was seen between the group with a financial compensation from the national health insurance system (median time of 12 weeks) and the group with income replacement by a private insurance company (median time of 8 weeks). Patients performing manual labour typically had a longer period of sick leave than other employees (12 versus 8 weeks). A longer absence from work was also observed in individuals who underwent a concomitant arthroscopic AC resection and patients with a higher BMI.
Impingement on the tendinous portion of the rotator cuff by the coracoacromial ligament and the anterior third of the acromion is responsible for a characteristic syndrome of disability of the shoulder. A characteristic proliferative spur and ridge has been noted on the anterior lip and undersurface of the anterior process of the acromion and this area may also show erosion and eburnation. The treatment of the impingement is to remove the anterior edge and undersurface of the anterior part of the acromion with the attached coracoacromial ligament. The impingement may also involve the tendon of the long head of the biceps and if it does, it is best to decompress the tendon and remove any osteophytes which may be in its groove, but to avoid transplanting the biceps tendon if possible. Hypertrophic lipping at the acromio-clavicular joint may impinge on the supraspinatus tendon when the arm is in abduction and, if the lip is prominent, this joint should be resected. These are the principles of anterior acromioplasty.
The measurement of outcome in the treatment of acid-related diseases can be assessed against the background of various types of economic evaluation. Apart from endoscopic confirmation of healing (or nonhealing), the measurement of outcome has been based on recording separately the occurrence of various symptoms and possible adverse effects, as experienced and reported by the patients. Findings have been reported as the proportions of total patients who are free from some or all symptoms. These proportions may be noted in terms of prevalence or incidence. However, unless one treatment dominates the others (is superior or at least is not worse) on all outcome measures, it is impossible to say conclusively which treatment is the best overall, provided of course that there is no difference between the treatments in the severity of symptoms and adverse effects. Decision trees have been built to combine some outcomes. However, in the future, measurements that give a more complete picture of the combined severity of various symptoms and adverse effects need to be adopted. These should help to assess how quickly and to what degree the severity of disease is affected by treatment. The emerging guidelines for economic evaluations encourage the measurement of outcome prospectively in terms of quality of life and/or survival, since for most drugs the ultimate outcome of therapy is to improve them, and expressing them as quality-adjusted life-years (QALYs) gained. Quality-of-life measures potentially appropriate for QALY calculations in acid-related diseases (EuroQol Group 1988; Kaplan & Anderson 1988; Rosser & Kind 1978; Sintonen & Pekurinen 1993) are briefly reviewed. Further, the use of decision analysis is encouraged to ensure that all relevant outcomes and their possibly changing probabilities over time are considered and quantified. Expressing results as proportions and numbers achieving specified targets (success) is recommended, because they are relatively easy to incorporate into economic evaluation. The use of cost-benefit analysis based on the human capital approach is discouraged, since there may not be an economic loss or benefit to society through a patient’s lack of, or return to, productive capacity.
Purpose of the studyClassically, the shoulder joint is thought to age more by its tendons than by its cartilages, the incidence of rotator cuff tears being considered to increase with age. The purpose of this work was to assess the natural history of the shoulder joint based on a clinical and radiological study of 200 patients aged 70 to 101 years.
The aim of this paper is to describe a physiotherapy method for treatment of patients with rotator cuff disease (impingement syndrome stages II and III). A comprehensive treatment programme based on biomechanics and the physiology of collagen tissue was designed in 1981. This method, which we call ‘supervised exercises’, is discussed in relation to recent biomechanical knowledge and clinical studies. ‘Supervised exercises’ emphasises reduction of mechanical subacromial stress, relearning of normal patterns of movement, specific endurance training to increase nutrition of the collagen tissue and simple advice to prevent relapse. In the presence of a positive impingement sign and test, a functional diagnosis is mandatory to pinpoint the cause of impingement as a guideline for an individual treatment programme. Reactivating the supraspinatus muscle to improve the initial movement pattern in abduction, together with promotion of agility of movement, are central elements of ‘supervised exercises’. Two large clinical studies have evaluated the treatment effect. A randomised, controlled study suggests that the supervised exercise regimen has a causative effect. The mechanisms are not clear and should be addressed in future studies.
The purposes of this study was to better understand the utilization of anterior acromioplasty over time, in the absence of rotator cuff repair; to examine the relation to patient characteristics (age, sex) and types of rotator cuff pathology (inflammation or fibrosis, partial-thickness tearing, full-thickness tearing undergoing debridement); and to assess the utilization of arthroscopy in this procedure. Using the resources of the Rochester Epidemiology Project, cataloging medical records of residents in Olmsted County, Minnesota, we identified 246 patients who underwent anterior acromioplasty between 1980 and 2005. It has previously been shown that rarely does a resident of Olmsted County undergo an orthopaedic procedure at a facility outside the county. The incidence of anterior acromioplasty increased over time (P < .001), with crude rates of 3.3 per 100,000 persons in 1980 to 1985 and 19.0 per 100,000 persons in 2000 to 2005. Sex, age, and types of rotator cuff pathology did not significantly change over the 26-year period. There was a dramatic shift from use of the open approach to the arthroscopic approach over this time period (P < .001) and a decrease in the concomitant performance of distal clavicle resection (P < .001). The frequency of anterior acromioplasty has dramatically increased over time. Increasing knowledge about this syndrome, including better imaging, has facilitated patient treatment for a stable spectrum of rotator cuff pathology (inflammation or fibrosis, partial-thickness tearing, full-thickness tearing undergoing debridement), as has the application of endoscopic surgery. Level III, epidemiologic study.
Acromioplasty is considered a technically simple procedure but has become controversial with regard to its indications and therapeutic value. Two complementary databases were used to ascertain the frequency of acromioplasty over a recent span of time. In Part A, the New York Statewide Planning and Research Cooperative System (SPARCS) ambulatory surgery database was searched from 1996 to 2006 to identify all ambulatory surgery acromioplasties as well as all orthopaedic ambulatory surgery procedures. In Part B, the American Board of Orthopaedic Surgery (ABOS) database was searched from 1999 to 2008 to identify all arthroscopic acromioplasties as well as all orthopaedic procedures. Part A revealed that in 1996 there were 5571 acromioplasties in New York State, representing a population incidence of 30.0 per 100,000. In 2006 there were 19,743 acromioplasties, representing a population incidence of 101.9 per 100,000. Over these eleven years, the volume of acromioplasties increased by 254.4%, compared with only a 78.3% increase in the volume of all orthopaedic ambulatory surgery procedures. In 2006, as compared with 1996, patients were 2.4 times more likely to have an acromioplasty compared with all other orthopaedic ambulatory procedures (p < 0.0001). Part B revealed that, in 1999, a mean of 2.6 arthroscopic acromioplasties were reported per candidate for Board certification. In 2008 a mean of 6.3 arthroscopic acromioplasties per candidate were reported. Over these ten years, the mean number of arthroscopic acromioplasties reported increased by 142.3%, compared with only a 13.0% increase in the mean number of all orthopaedic surgery procedures. In 2008, as compared with 1999, candidates were 2.2 times more likely to report an arthroscopic acromioplasty compared with all other orthopaedic procedures (p < 0.0001). There has been a substantial increase in the overall volume and the population-based incidence of acromioplasties in recent years on both the state and national levels in the United States. The reasons for this increase have yet to be determined and are likely multifactorial, with patient-based, surgeon-based, and systems-based factors all playing a role.
We report a randomised controlled trial to examine the effectiveness and cost-effectiveness of arthroscopic acromioplasty in the treatment of stage II shoulder impingement syndrome. A total of 140 patients were randomly divided into two treatment groups: supervised exercise programme (n = 70, exercise group) and arthroscopic acromioplasty followed by a similar exercise programme (n = 70, combined treatment group). The main outcome measure was self-reported pain on a visual analogue scale of 0 to 10 at 24 months, measured on the 134 patients (66 in the exercise group and 68 in the combined treatment group) for whom endpoint data were available. An intention-to-treat analysis disclosed an improvement in both groups but without statistically significant difference in outcome between the groups (p = 0.65). The combined treatment was considerably more costly. Arthroscopic acromioplasty provides no clinically important effects over a structured and supervised exercise programme alone in terms of subjective outcome or cost-effectiveness when measured at 24 months. Structured exercise treatment should be the basis for treatment of shoulder impingement syndrome, with operative treatment offered judiciously until its true merit is proven.
In a prospective randomised study we compared the results of arthroscopic subacromial bursectomy alone with debridement of the subacromial bursa followed by acromioplasty. A total of 57 patients with a mean age of 47 years (31 to 60) suffering from primary subacromial impingement without a rupture of the rotator cuff who had failed previous conservative treatment were entered into the trial. The type of acromion was classified according to Bigliani. Patients were assessed at follow-up using the Constant score, the simple shoulder test and visual analogue scores for pain and functional impairment. One patient was lost to follow-up. At a mean follow-up of 2.5 years (1 to 5) both bursectomy and acromioplasty gave good clinical results. No statistically significant differences were found between the two treatments. The type of acromion and severity of symptoms had a greater influence on the clinical outcome than the type of treatment. As a result, we believe that primary subacromial impingement syndrome is largely an intrinsic degenerative condition rather than an extrinsic mechanical disorder.