Which patients do not recover from shoulder impingement syndrome, either with operative treatment or with nonoperative treatment?

Abstract

Background and purpose — Shoulder impingement syndrome is common, but treatment is controversial. Arthroscopic acromioplasty is popular even though its efficacy is unknown. In this study, we analyzed stage-II shoulder impingement patients in subgroups to identify those who would benefit from the operation.

Patients and methods — In a previous randomized study, 140 patients were either treated with a supervised exercise program or with arthroscopic acromioplasty followed by a similar exercise program. The patients were followed up at 2 and 5 years after randomization. Self-reported pain was used as the primary outcome measure.

Results — Both treatment groups had less pain at 2 and 5 years, and this was similar in both groups. Duration of symptoms, marital status (single), long periods of sick leave, and lack of professional education appeared to increase the risk of persistent pain despite the treatment. Patients with impingement with radiological acromioclavicular (AC) joint degeneration also had more pain. The patients in the exercise group who later wanted operative treatment and had it did not get better after the operation.

Interpretation — The natural course probably plays a substantial role in the outcome. Based on our findings, it is difficult to recommend arthroscopic acromioplasty for any specific subgroup. Regarding operative treatment, however, a concomitant AC joint resection might be recommended if there are signs of AC joint degeneration. Even more challenging for the development of a treatment algorithm is the finding that patients who do not recover after nonoperative treatment should not be operated either.

All the authors participated in the conception and conduction of the study, and contributed to the final manuscript. SK, TR, MN, and IA: (overall) planning of the study (TR especially the physiotherapy aspects, IA especially the operative aspects). SK: substantial intellectual contribution. SK and TR: seeking permission from the ethical committee. SK, TR, MN, and IA: seeking permission from the hospitals. SK, JL, and MN, recruitment of the patients. SK, JL, and IA: organization of the study. SK: collection and organization of the data. SK and HH: statistics. JL, TR, and IA: clinical analysis of the data. SK and JL: literature review. SK and JL: writing of the draft. SK, JL, TR, MN, HH, and IA: critical commenting on and improvement of the manuscript.

No competing interests declared.

The late Professor of medicine Y. T. Konttinen from Helsinki University Central Hospital is gratefully acknowledged for his contribution to this shoulder study.