The Most Common Shoulder Surgery Is No Better than A Placebo

By Jane Farrell

Researchers have found that one of the most common shoulder operations – shoulder impingement surgery – has no more benefit than placebo surgery. Shoulder impingement occurs when muscles become inflamed, causing weakness and limitation in movement.

In a follow-up two years after the newest study, known as the Finnish Shoulder Impingement Arthroscopy Controlled Trial (FIMPACT), both those in the group who underwent surgery and the ones in the placebo group had equally little shoulder pain and were equally satisfied with the overall situation of their shoulder.

“These results show that this type of surgery is not an effective form of treatment for this most common shoulder complaint. With results as crystal clear as this, we expect that this will lead to major changes in contemporary treatment practices,” said the study’s principal investigators, chief surgeon Mika Paavola and professor Teppo Järvinen from the Helsinki University Hospital and University of Helsinki.

Shoulder problems are very common and place a significant burden on the health care system. The most common diagnosis for shoulder pain that requires treatment is shoulder impingement, and the most common surgical treatment is minimally invasive arthroscopic surgery. This procedure involves the visual examination of the interior of a joint with an arthroscope to diagnose or treat various conditions or injuries of a joint and to repair or remove damaged or diseased tissue or bone.

“With nearly 21,000 decompression surgeries done in the UK every year, and ten times that many in the United States, the impact of this study is huge,” said adjunct professor Simo Taimela, the research director of the Finnish Center for Evidence-Based Orthopedics (FICEBO) at the University of Helsinki.

This latest research confirms previous randomized studies showing that arthroscopic surgery of the shoulder does not alleviate the symptoms of patients any better than physiotherapy. Paradoxically, however, the number of such surgeries has increased significantly, even though solid proof of the impact of the surgery on the symptoms has been lacking.

The FIMPACT study involved 189 patients suffering from persistent shoulder pain for at least three months despite receiving conservative treatment, physiotherapy and steroid injections. Patients were randomized to receive one of three different treatment options, subacromial decompression surgery, placebo surgery (diagnostic arthroscopy, which involved arthroscopic examination of the shoulder joint but no therapeutic procedures) or supervised exercise therapy.

No one involved in the study – including the patients, the persons involved in their care after surgery, and the researchers who analyzed the results – knew which patient was in the decompression or placebo group, according to a news release from the University of Helsinki.

Two years after the start of the study, patients were asked about shoulder pain and other symptoms they had experienced, as well as their satisfaction with the treatment and its results. The patients in the decompression or placebo groups were also asked which group they believed they had been in – actual surgery or placebo.

Overall, shoulder pain was substantially improved in all three groups from the start of the trial. However, decompression surgery offered no greater benefit to shoulder pain than placebo surgery. The patients in the diagnostic arthroscopy group were no more likely than those in the decompression group to guess that they had had a placebo procedure.

The group that received exercise therapy also improved over time, to the point that patients who initially had decompression surgery were only slightly more improved than those who had physiotherapy only. Although this latter finding could be interpreted as evidence to support the decompression surgery, the authors did not find the difference in improvement to be clinically significant.

“Based on these results, we should question the current line of treatment according to which patients with shoulder pain attributed to shoulder impingement are treated with decompression surgery, as it seems clear that instead of surgery, the treatment of such patients should hinge on nonoperative means,” Järvinen said. “By ceasing the procedures which have proven ineffective, we would avoid performing hundreds of thousands of useless surgeries every year in the world. Fortunately, there seems to be light at the end of the tunnel as the NHS [National Health Service] in England just released a statement that they will start restricting funding for ‘unnecessary procedures,’ and the list includes subacromial decompression. We applaud this initiative and encourage other countries to follow this lead.”

Taimela concluded, “We have to spend taxpayers’ money responsibly. If we are spending money on procedures that are not effective, that money is deprived from treatments that are clinically effective and would provide benefits to patients. One component in becoming more efficient is to make sure we are not undertaking unnecessary procedures.”

The findings were published in The BMJ in July 2018.