Shoulder X-Ray

Does Subacromial Decompression Surgery Really Do Anything?

Subacromial decompression surgery is a very common procedure performed for people with shoulder pain.  The procedure is often recommended for people with “shoulder impingement” and was originally theorized to open up the subacromial space and help reduce biomechanical impingement.  

But recent research has challenged the effectiveness of the procedure, and even the diagnosis of “subacromial impingement” itself.

Subacromial Decompression Surgery for Adults with Shoulder Pain: A Systematic Review with Meta-Analysis

A recent article in the British Journal of Sports Medicine reviewed the results of 9 clinical trials in over 1000 patients with shoulder pain.  The authors includes studies that compared subacromial decompression surgery with placebo surgery and exercise therapy.

The study noted that subacromial decompression surgery provided no important benefit compared with placebo surgery or exercise therapy. 

In particular, they found that surgery did not provide any additional benefit for pain, function, and quality of life at the 6- and 12-month mark after surgery.

Pain-Time diagram

Function-Time Diagram

As you can see, there does not appear to be a significant benefit in undergoing subacromial decompression surgery for shoulder pain or function.

What’s All This Mean?

Based on the results of several studies recently, it sure looks like we’re going to be seeing less subacromial decompression surgeries in the future.

It seems like the benefit of undergoing surgery may be related to the postoperative rehabilitation and application of graded exercise postoperatively.

This is another one of those surgical procedures that seems like it was missing the boat anyway.

Thinking purely biomechanically, rather than addressing the underlying concern that may be causing “impingement,” such as stiffness or loss of dynamic stability, we simply just make more space?  

Seems overly simplistic, right?

We probably haven’t address the underlying cause.

But based on all this, perhaps we shouldn’t even be using the term “impingement” anyway.

From a non-biomechanical perspective, I’m not even sure we truly understand the etiology of shoulder pain at times and always seem to rush towards a biomechanical “impingement” approach.  There could be numerous reasons why graded exercise can help reduce shoulder pain other than purely biomechanical factors.

But let’s not forget one main point here from this study.  At 5 years down the road, these patients still had shoulder pain between a 1.5 and 3 out of 10 on a visual analog scale.  

So advising people to ignore the biomechanics and simply work through some pain may not be an ideal approach as well.  

I’d hate to see us go down that road.

These patients had shoulder pain for greater than 3 months to be included in this study.  It’s difficult to quantify the degree of rotator cuff pathology present in these people, how this impacted their shoulder function, and what their long term prognosis will be going forward.  There is still underlying inflammation of the rotator cuff.

Subacromial impingement

Image from Wikipedia

So What Should We Do?

As research like this continues to be published, we’re probably going to be seeing less of these procedures.

Maximizing the function of the shoulder is going to become even more important, regardless of whether or not something is causing “impingement.”  

I’ve had a lot of success with people by keeping it simple.  Rather than worry about the exact specifics of the pain, just simply focus on normalizing motion, increasing strength of the rotator cuff and scapular muscles, enhancing dynamic stability, and then gradually building tissue capacity through loading.

This is a great example of when focusing on the functional deficits is more impactful than the structural diagnosis.  

Optimize the person, don’t just treat the pain.

6 replies
  1. Mike Monahan
    Mike Monahan says:

    Mike R,
    Thanks for bringing the current information to the table for discussion. I would love to hear more on your take to “normalize motion (of the shoulder)”, unfortunately, I see too much emphasis on “exercise for the shoulder” in the clinic and not enough assessment of landmark positions which helps to define the flexibility and proper strength of the scapular mm. in the general population, we see far too much inflexibility in the latissimus dorsi m, pectoralis minor, weakness in the SA,LT,UT mm of the scapulae and maybe even poor mobility of the thoracic spine. All the rotator cuff strength in the world won’t overcome these deficits. The skills that separate us from personal trainers is the ability to assess and the use of manual techniques to affect change.

  2. Jake Menotti
    Jake Menotti says:

    I think it’s one thing to challenge the efficacy of this surgery, but quite another to challenge the diagnosis of subacromial impingement. Seems to be a classic example of throwing the baby out with the bath water to me. More than likely, there were probably many people who did not necessarily need the surgery that got it compared to those who truly benefited from it along with post-surgical rehab. Mike hit it on the head – the underlying causes such as poor dynamic stability and others – are in my opinion central to the underlying biomechanical changes that likely contribute to impingement in many cases. We know that osteoblast activity increases via increased mechanical forces we place upon bone. Thus, the person with an acromion that “hooks” downward may just build that bone right back to where it was post-surgery unless the predisposing factors can be corrected via rehab (i.e. shoulder biomechanics, ROM, muscle length, scapular stabilizer/RC strength, dynamic stability/neuromuscular stability, etc). Obviously, there may be genetic factors playing a role as well, but no single approach works for everyone, so treating the individual is key in my opinion. Therefore, I think that this surgery will not completely go away, but more people will likely need to fail conservative care such as rehab first prior to undergoing it. Even those who need it will likely need rehab post-surgery for the reasons stated previously as well.

  3. Teresa Merrick
    Teresa Merrick says:

    I had subacromial decompression (SAD) a little over 10 years ago on my right (dominant) shoulder along with distal clavicle resection and repair of a small full-thickness tear (1 cm or so as I recall) of the supraspinatus. Over the years preceding I had struggled with issues of impingement, pain, and performance out of that shoulder; pushups, bench presses, etc. At one time, the diagnosis had been bicep tendinitis (long before it seemed they recognized rotator cuff issues). I had done PT several times over those years, so I was familiar with the exercises, but they weren’t working any more for me. I feel the surgery was just what was needed: open up more space for the tissues of the right shoulder to operate. At 5 1/2 months post surgery, my PL bench press was only 2.5 kg less than the previous year (before the culminating event that led me to choose surgery over trying a cortisone shot). For the right patient and right problem, SAD can be the right procedure.

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