So, in this blog we will finish off our three articles discussing the topic of shoulder surgery vs physiotherapy. In our previous articles we used a case study of a male in his mid 30s with shoulder pain to illustrate some of the difficulties surrounding testing the shoulder, diagnosing which structure has been injured, the pros and cons of scans and the possibility that many injuries picked up on scans have been there for many years. In this blog we shall continue with our case study and try and examine if surgery is merited in his case, when it might be advisable to consider surgery (or at least a surgical opinion) and some of the current research around shoulder surgery.

In our case study we have a male in his mid 30s who has ongoing shoulder pain and has been following a programme of rehab exercises aimed at getting him back to the gym and lifting weights. It is now approximately 3 months since he began receiving physiotherapy and he has had about 5 sessions all aimed at slowly progressing his exercises and improving his shoulder strength. His pain has lessened to a niggle now, he gets occasional flare ups if he lifts a bit more than usual in the gym but overall he thinks he is about 90% fixed and is generally going the right direction.

So, clearly in this case our patient does not need shoulder surgery and he is generally happy with things and feels that given some more time his shoulder should sort itself out now. A different and more interesting question would be: “Would surgery have returned him to sport more quickly?” I am afraid to say that is a topic for another blog and one that the jury is still very much out on at present. We will look at a few different situations later that illustrate when surgery is certainly advisable and when it certainly isn’t. Firstly though I think it is worth very briefly considering what the research says about how effective shoulder surgery actually is. A word of warning, this is very much an area of current research and it is possible that the research on shoulder surgery and its effectiveness may well change substantially over the next few years. Okay, firstly it should be easy to decide if a really common shoulder surgery such as sub-acromial decompression for a common condition like shoulder impingement or sub-acromial pain actually works. Well despite this operation being performed a large number of times each year and being basically the go to operation when someone has shoulder pain its actual effectiveness is very much uncertain! The following study compared sub-acromial decompression versus a simple arthroscopy (ie cutting into the shoulder but not actually doing the important decompression and bone shaving bits!) alone and found minimal difference between the two! https://www.ncbi.nlm.nih.gov/pubmed/29169668  Another study  http://bjsm.bmj.com/content/bjsports/early/2017/05/11/bjsports-2016-097098.full.pdf compared sham surgery (patients had incisions made in the skin of the shoulder) versus actual surgery for type II SLAP lesions (a particular type of shoulder injury) and found no significant benefits to actual surgery!!

So does this mean that all shoulder surgeries are useless and should be stopped? Well, no, it possibly means that we really aren’t exactly sure why shoulder surgery seems to work with some patients (and my experience is that it does), We need to do more research on who should be having shoulder surgery and who should just have physiotherapy. Also there is undoubtedly a large element of placebo in shoulder surgery and the extensive period of rest and then a structured rehab programme, likely plays a large role in how surgery overall works. I think it is important to be clear here that I am not anti-shoulder surgery, my personal experience is that there are some people who do a lot of rehab, are very disciplined and follow all my advice and still their shoulder does not improve and for these people shoulder surgery seems to really help. How to identify these people early is a topic of current research and unfortunately there does not seem to be a way to do this at present.

Lastly in our case study of a male in his mid 30s with shoulder pain it could be helpful to look at a few situations where I may well have recommended a surgical opinion.

1. If our patient with ongoing shoulder pain was unable to hold his hand out to the side at all then this would be indicative of a full thickness rotator cuff tear and I think given his age and desire to return to sport it would seem reasonable to get a surgical opinion as soon as possible.
2. He returns after doing a month of progressive rehab, has done everything I asked diligently and his shoulder has got worse. In this case, although very early in the process, given his age and wish to get back to sport I think it is okay to discuss imaging and possible surgery. Some patients at this point confess that they haven’t actually followed everything to the letter and they would like to try another month of rehab first!
3. If after 3 months of rehab and being very diligent with things, his shoulder has improved but still flares up significantly on a semi-regular basis and he is finding it difficult to return to his sport even at an easier level. I think then this is a candidate for discussing surgery. Again, surprisingly, patients often decide that they want to give it a bit more time at this point!

Okay, I hope you have found this article looking at the pros and cons of shoulder surgery helpful If you have any questions or would like help with shoulder pain, we can be contacted on enquiries@threespiresphysiotherapy.co.uk or 07884281623