Expert panel strongly recommends against surgery for the most common shoulder pain

Surgery should not be performed in almost all patients with a common cause of shoulder pain known as subacromial pain syndrome or SAPS (also called shoulder impingement or rotator cuff disease), say a panel of international experts in The BMJ today.

Their strong recommendation against surgery is based on new evidence that it does not sufficiently improve pain, movement, or quality of life compared with other treatment options.

This new and sound evidence should change practice, given the risk of harm and burden to patients and waste of health care resources, they say.

Their advice is part of The BMJ Rapid Recommendations initiative—to produce rapid and trustworthy guidance based on new evidence to help doctors make better decisions with their patients.

Subacromial pain syndrome refers to non-traumatic pain, weakness or loss of movement around the shoulder, particularly when lifting the arm.

It is common in people over 40 years old and decompression surgery is a common way to manage symptoms if they do not resolve after simple treatments. There were 21,000 procedures performed in NHS hospitals in 2010, which cost around £50 million.

Yet recent trials found that decompression surgery provided no benefit over placebo surgery, or other options such as painkillers, exercises, and steroid injections.

So an international panel—made up of bone surgeons, physiotherapists, clinicians and patients with experience of shoulder pain and surgery, decided to carry out a detailed analysis of the latest evidence and create a recommendation according to standards for trustworthy guidelines and the GRADE approach (a system used to assess the quality of evidence).

Their strong recommendation against surgery is based on two systematic evidence reviews, one on the benefits and harms of decompression surgery and another on meaningful improvements in pain, movement, and quality of life valued by patients.

The panel was confident that surgery provides no important benefit on pain, function, quality of life, or overall perceived effect. Surgery is also burdensome, has potential for serious harm, and is expensive, they add.

The panel felt that almost no one who fully understands the evidence would choose to have surgery.

"Clinicians should not offer patients subacromial decompression surgery unprompted, and clinicians, public healthcare providers, and others should make efforts to educate the public regarding the ineffectiveness of surgery," they write.

However, they point out that there is substantial uncertainty around what would be better offered as an alternative.