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Shoulder Impingement Not Helped by PT Won't Benefit From Arthroplasty Either

Arthroplasty takes another hit: A group from Finland reports that, besides being no better for shoulder impingement syndrome than an exercise program, it doesn't help those who gain no relief from the physical therapy.

Ketola S, Lehtinen J, Rousi T, et al.Which patients do not recover from shoulder impingement syndrome, either with operative treatment or with nonoperative treatment?Acta Orthop. 2015; 26:1-6. [Epub ahead of print] doi:10.3109/17453674.2015.1033309

Physical therapy works just as well as arthroplastic surgery to relieve pain for most patients with shoulder impingement syndrome, this team from Finland reports. But it's still not clear that either is better than doing nothing, they add, and patients who don't benefit from exercise aren't helped by resorting to the operation.

The purpose of this analysis of the prospective study was to identify subgroups of patients who could expect to benefit from arthroplastic acromioplasty, given that  results from this group and others show no significant advantage for that procedure over exercise therapy.

The original study randomized 140 patients to either exercise alone or exercise plus surgery. All patients had MRI at baseline, and the same surgeon performed all procedures. Two and 5 years later, the researchers measured self-reported pain on a 0-10 scale, as well as secondary outcomes relating to disability and quality of life.

After 5 years, 75% of patients in both groups were pain-free. Similar to results for other orthopedic procedures, those who still had significant pain were more likely to be single, not professionally educated, to have jobs that were stressful or unsatisfying or required lots of heavy lifting, or to have had pain for at least one year at baseline.

In the exercise-only group, 18 patients opted for surgery later because the exercise program had not helped, They did not get better after surgery, and continued to show worse pain than the other groups. This difference does not reach statistical significance, but nonetheless raises serious questions about the wisdom of resorting to surgery as a last resort, the authors say.

The only exception is patients with degenerative osteoarthritis of the shoulder, they add, for whom a concomitant acromioclavicular resection is justified. The team reported these results at the recent annual meeting of the American Academy of Orthopaedic Surgeons.

They also caution that we still have no idea how much of the improvement in either group is due to the natural history of the disease.