Shoulder impingement syndrome decompression surgery – What are your alternatives?
Ross Hauser, MD
- After a more powerful and perhaps prolonged anti-inflammatory regimen and ultimately a cortisone injection, you find yourself with maybe a little improvement.
- My shoulder impingement syndrome conservative care treatments sent me to shoulder replacement.
- I was injured at work, the doctors discovered an impingement.
- Maybe you are not a physical laborer, maybe you do not play sports or workout, but carrying groceries and wearing a handbag is causing shoulder pain
- You have already rested and tried to alleviate your shoulder problem with anti-inflammatories and painkillers and you still have a problem? Now what?
- Cortisone and Physical Therapy for shoulder impingement?
- “The initial treatment of conservative care with non-steroidal anti-inflammatory drugs, cortisone, and patient exercises yielded satisfactory results within 2 years in 60% of cases.”
- How about laser therapy for shoulder impingement?
- Is Shoulder impingement syndrome actually a symptom of a bigger shoulder problem? Do you even have Shoulder impingement syndrome?
- “Surgical treatment should have no role in the treatment of such (Subacromial impingement syndrome) patients.”
- Arthroscopic treatment should no longer be offered to people with subacromial impingement.
- More research: Impingement of the shoulder cannot be treated as an isolated injury. You need to treat the whole shoulder.
- Treating Shoulder impingement syndrome as part of a problem of degenerative shoulder disease.
- Research: Surgery for shoulder impingement syndrome is “useless.” Is it really?
- Surgery and Physical Therapy or Physical Therapy alone for shoulder impingement syndrome? Which Benefits patients most? Surgeons say they can’t tell.
- Is surgery useless? Is no better than physical therapy alone? Then what type of treatments can I get?
- The patient had a rounded shoulder posture causing impingement.
- An overview of Prolotherapy injections for the treatment of shoulder impingement syndrome: Caring Medical research.
Shoulder impingement syndrome – Surgeons tell patients to say no to surgery – What are your options?
You started having some shoulder pain and a limited range of motion. Maybe you had an injury at work or your shoulder has been getting worse and worse over the years. You started to find it increasingly more difficult to reach above your head for something. You took some over-the-counter pain relief pills, maybe tried a rotation of heat and ice, and started to sleep in different ways because of your night time and woke you up from sleep shoulder pain. Finally, and perhaps after months and years of chronic problems and self-management, you finally went to get some medical attention.
At the doctor’s office and after an examination, your doctor/clinician may explain to you that your problem is all about inflammation or “itis.” You have a shoulder impingement, and your shoulder muscles and tendons are getting squeezed between the bones of the shoulder. How did that happen? You wondered but you knew that years of activity had been leading you to a loose and wobbly shoulder. Your shoulder is basically worn and tearing away. So you have an “itis.” This could be rotator cuff tendinitis, shoulder bursitis, or a combination of both.
Your clinician may have explained that the bursae (plural because you have more than one bursa in the shoulder), is a fluid-filled sac that helps to reduce frictional wear and tear in your shoulder. The clinician may have even mentioned the subacromial bursa, the bursa that sits between your rotator cuff tendons, and the acromion process of the scapula. It may have been pointed out to you that the shoulder tendons that run over the shoulder bursae are causing too much friction. So what can you do about this? You need anti-inflammatories.
This may have been a disappointing answer for you. You are probably already on a self-medication regimen of over-the-counter anti-inflammatory medications. You may have even justified the need for more anti-inflammatories as “Maybe the stronger stuff will work better.” Some people, do work better and the shoulder pain can be managed.
These are the people we do not typically see at our center. We see the people who are not really being helped by the better, stronger medications and are looking for something else.
After a more powerful and perhaps prolonged anti-inflammatory regimen and ultimately a cortisone injection, you find yourself with maybe a little improvement
So after a more powerful and perhaps prolonged anti-inflammatory regimen and ultimately a cortisone injection, you find yourself with maybe a little improvement, but certainly not enough to get you back to work or sport.
- X-ray and MRI were ordered and your doctors are not really sure what they are saying. So you are sent to physical therapy to help your shoulder. There your physical therapists may make other recommendations. Maybe it is a problem with your neck moving into your shoulder. Weeks of exercise did not show this to be true as the shoulder pain and lack of range of motion remain.
- At this point, surgery is thought to be the only answer. For many people, surgery may be the only answer. Some people do very well with surgery. These are not the people we see in our office. We see the people for whom surgery is given only a modest chance of working or the people who had the surgery and their situation was made worse.
If you are reading this article you have probably reviewed many articles which line up the symptoms and treatment of Shoulder impingement syndrome for its readers. Most of the articles will repeat the same primary symptoms and the same primary treatment course, rest, and anti-inflammatory medication. If you are here reading this article it is very likely that the conservative care primary treatment course is not working for you.
My shoulder impingement syndrome conservative care treatments sent me to shoulder replacement.
Here is a story:
After dealing with shoulder pain for a long time, I got to the point that I no longer wanted to deal with the chronic pain and for me, what was worse, the accelerated loss of range of motion. Suddenly, I could not move my arm. So I finally went to the doctor.
My regular doctor told me that my shoulder pain and limited range of motion were because I had an impingement. Fast forward some two years later now I need a shoulder replacement.
Here were my treatments: I started out with Voltaren gel which I bought online. Didn’t help. Then I was prescribed Comfort Pac-Meloxicam for tendinitis and pain. Didn’t help. Then a cortisone injection. Helped a little, but wore off. Then I was given cyclobenzaprine, the muscle relaxant. When this did not help, I was prescribed an anti-depressant because it would help with the pain, and the “extra bonus,” was that it might help with my mood.
After two years of conservative treatment, my shoulder had deteriorated to such a state that I developed fractures, and shoulder replacement was strongly recommended. In fact, it was “my only option.”
I was injured at work, the doctors discovered an impingement
Sometimes we will be contacted by someone who had an injury at the workplace. Their story goes something like this:
I hurt my shoulder at work. It was an acute injury from years of wear and tear damage. I thought I had a full-blown rotator cuff tear. My shoulder had been a problem for years. The doctors told me I had shoulder impingement syndrome. I was prescribed anti-inflammatory medications, a dozen sessions of physical therapy, and finally a corticosteroid injection. After almost four months of this, I went back to work. First day back, no change. My shoulder hurt so bad I could not work. I am starting all over again.
Maybe you are not a physical laborer, maybe you do not play sports or workout, but carrying groceries and wearing a handbag is causing shoulder pain
Maybe you are not a physical laborer, maybe you do not play sports and work out. Many women describe that part of their regular daily routine of activities is simply going food shopping two to three times a week. It’s good exercise, walking the aisles for an hour or more. You have been going to physical therapy, and you may be proceeding well, but you still cannot lift the groceries you buy. So you have the bag person put fewer items in each bag, and you carry your handbag on the other shoulder. For some people, these adjustments will be helpful but they will also be a daily reminder that they have a shoulder problem. For some people, these adjustments and physical therapy will be all they need. For some people, these adjustments and physical therapy will be all they need, for others these adjustments and physical therapy will go on for a long-time, not produce the results of where the patient wishes to be physically, and then surgery will be called for.
You have already rested and tried to alleviate your shoulder problem with anti-inflammatories and painkillers and you still have a problem? Now what?
If you are like our patients:
- You are likely concerned that your shoulder problem which is already making doing your physically demanding job difficult at best or playing your sport, will eventually progress to making it impossible to do your job or continue in your sport. Shoulder impingement syndrome can lead to rotator cuff tears and surgery.
- You are an athlete, a swimmer, an athlete that throws a ball, or anyone who plays a sport with your hands over your head you may be wondering how much more time are you going to lose.
You may have just returned from your first or follow-up visit to your healthcare provider. Now what? More pain management? More rest?
You may have just returned from your first or follow-up visit to your healthcare provider. You may be frustrated. He/she wants to start or continue you on a “conservative care” approach to dealing with your shoulder impingement. They would like to try the non-surgical route as long as possible. The reasons for not going to surgery are explained below. The news is not good.
- As Shoulder Impingement Syndrome is sometimes called “Swimmer’s Shoulder,” we would like to invite you to read our article Swimmer’s shoulder treatment | subacromial shoulder pain. In this article, we discuss the research that has shed light on several specific shoulder injuries that often are incurred by the competitive swimmer that may be bundled under the single diagnosis of subacromial impingement syndrome.
More pain management:
Your healthcare provider may suggest a prolonged, up to a two-month program of anti-inflammatories and painkillers. If you are not getting results somewhat immediately from these medications, your medications will be changed and given in a stronger dose until the one that works is found.
- The anti-inflammatory or NSAIDs (Non-Steroidal Anti-Inflammatory Drugs,) are thought to be a first-line treatment as your impingement problem is causing swelling and painful inflammation. This is a treatment that we do not recommend. In our article When NSAIDs make the pain worse, we show the research that:
- NSAIDs’ temporary reduction of pain, stiffness, and swelling comes at a great long-term expense, the destruction of cartilage and shoulder stability.
- Stronger pain medications. This particular recommendation has very little long-term appeal as it can make your situation worse. Please see our article, when Painkillers make the pain worse.
- Corticosteroids/cortisone or steroid injection. (This is also a treatment we do not recommend. Please see our article Alternative to cortisone shots, in which we examine new research that is providing more warnings that cortisone does not heal and, in fact, accelerates the deterioration of already damaged joints.)
- Your healthcare provider may prescribe rest or avoidance of shoulder motion that is causing the pain.
- Many of your reading this article have probably already done that. That is why you are reading this article, you need some more answers.
Cortisone and Physical Therapy for shoulder impingement?
Many people benefit from cortisone and physical therapy. These are not the people we see in our clinics, we see the patients who did not get the benefit of pain relief they had hoped for from cortisone and physical therapy.
Often a patient will explain to us:
I have been treated for tendonitis and impingement for over a year now. I had a cortisone injection and I thought I was cured. After 2 weeks, the pain came back. Don’t get me wrong, I was happy to have the two weeks being pain-free but the pain came back, worse than before. I started physical therapy after that. I found the whole experience to be very painful and I did not see any benefit. I have been told to keep trying physical therapy because the surgery may not help me either in the long run.
Researchers at Stellenbosch University in South Africa published a comprehensive evaluation of conservative care treatment options for shoulder impingement syndrome in The South African Journal of Physiotherapy (1). In addressing a direct comparison of cortisone injection to physical therapy the researchers noted these results in patients:
- Besides a significant improvement in shoulder function in favor of cortisone injection at 6–7 weeks’ follow-up, no evidence was found for the superiority of cortisone injection compared with physiotherapy for pain and Range of Motion (ROM) in the short term.
- The medium- and long-term outcomes for pain, ROM, and shoulder function do not favor the use of cortisone injection over physiotherapy.
As we mentioned, people do get good results from cortisone. Even those of you who are reading this article may have benefited from cortisone injections initially. But there is a limit to cortisone’s effectiveness and when you reach that limit cortisone becomes detrimental to your healing.
“The initial treatment of conservative care with non-steroidal anti-inflammatory drugs, cortisone, and patient exercises yielded satisfactory results within 2 years in 60% of cases.”
Our opinion meets with that of numerous research studies. At the Department of Trauma, Shoulder and Hand Surgery at Agatharied Hospital Hausham Germany, (2) doctors published their findings in conservative care management of their patients with shoulder impingement syndrome. What they found was:
- The initial treatment of conservative care with non-steroidal anti-inflammatory drugs, cortisone, and patient exercises yielded satisfactory results within 2 years in 60% of cases.
- Corticosteroid injections to lessen acute pain and improve shoulder mobility in the first eight weeks are a standard form of treatment
- Cortisone must be injected in the vicinity of the tendons, not into the tendons themselves. (Cortisone damages tendons).
- The injections should be repeated no earlier than 3–4 weeks after the initial injection, and no more than 2 or 3 times.
Adding a nerve block
An April 2020 study in the Archives of Orthopaedic and Trauma Surgery (3) studied the effect of the combination of subacromial corticosteroid injection and suprascapular nerve block on shoulder impingement syndrome.
- 66 patients (average age 55) with shoulder impingement syndrome were randomly divided into two groups (33 patients per group):
- Group 1: cortisone for shoulder impingement syndrome only;
- Group 2: cortisone plus nerve block for shoulder impingement syndrome.
- Patients were then assessed at one and three months after treatment.
According to the study, both treatment groups showed significant relief of pain at one and three months after treatment. However, the cortisone plus nerve block group showed better pain relief.
Let’s point out here that any treatment that brings pain relief to people is a good treatment. Some people are very satisfied with symptom suppression. However, others, those who need to work or have physically demanding needs, such as being a caregiver to a spouse, know that symptom suppression is not a\treating the problem. Eventually, cortisone will wear off. If you are reading this article it is very likely that cortisone may have worn off for you.
What are we seeing in this image?
This illustration demonstrates shoulder impingements as caused by shoulder instability. In external impingement, the rotator cuff tendons are compressed by the acromion process. In internal impingement, the structures within the glenohumeral joint themselves have impinged. These conditions can be caused by excessive shoulder instability.
At our clinics, we frequently work with physical therapists who are treating shoulder impingement patients. For physical therapy to achieve maximum benefit, the shoulder capsule itself has to be capable of providing muscle resistance. If the tendons of the rotator cuff and the ligaments that hold the bone structure of the shoulder are compromised, as seen by excessive shoulder instability and hypermobility, including partial dislocation, the shoulder may not be able to provide the resistance needed for maximum gain.
How about laser therapy for shoulder impingement?
Like every medical treatment, including those we offer at our center, some people will do very well, some people will do okay, and some people may not respond as well. This could be the case made about low and high-intensity lasers.
Laser therapy is considered safe, little if any pain is involved in the treatment and it may help. Red infrared laser light is placed against the shoulder. The idea is that the photons (a particle of light) will penetrate into the cells and revitalize the healing process by jump-starting the mitochondria in the cells. Mitochondria are the energy centers of the cells – the power generators. Turn them on, the theory goes, you turn on healing. How? Mostly it is about bringing blood flow and increased circulation into the area. In principle that is how all healing treatments work.
A May 2019 paper in the journal Clinical Rehabilitation (4) evaluated the effectiveness of high-intensity laser therapy on shoulder pain and function in subacromial impingement syndrome. The study included 46 patients.
- Some in the group of patients received high-intensity laser therapy + exercise therapy
- Some of the group of patients were put into a control group (sham-laser + exercise therapy)
- The groups then received 15 sessions of treatments, five days a week for three weeks.
- Patients were evaluated at:
- baseline, the start of treatment
- after 15 sessions,
- and at one month and at three months after completing the treatments.
What these researchers found was the laser did not help the patients any more than just the exercise alone: “The effect of high-intensity laser therapy plus exercise is not higher than exercise alone to reduce pain and improve functionality in patients with the subacromial syndrome.”
A December 2020 paper, also in the journal Clinical Rehabilitation (5) gave a more optimistic outlook. In this study, low-level laser therapy (LLLT) was combined with exercise for shoulder pain and disability in patients with subacromial impingement syndrome.
- 120 patients
- In Group I, 42 patients (average age 52) were treated with Low-level laser therapy and exercise.
- In Group II, 42 patients (average age 56) were treated with exercise only.
- In Group III, 36 patients (average age 54) were treated with Low-level laser therapy only.
- Patients in all groups received treatment three times a week for 8 weeks.
In comparison, the researchers found that “Low-level laser therapy combined with exercises reduce pain intensity, improve shoulder function and reduces pain intensity and medication intake over 3 months.”
Is Shoulder impingement syndrome actually a symptom of a bigger shoulder problem? Do you even have Shoulder impingement syndrome?
In our clinics, we do not like to describe shoulder impingement as a diagnosis. We like to describe it as a symptom of a bigger shoulder problem, that of shoulder instability. What this means is that if you try to repair shoulder impingement alone without addressing the problems of the unstable shoulder, it is likely you will not have as much success in treatment as you may have hoped for.
If you are like many of our patients or someone who researches the internet a lot, this already has made a lot of sense to you. Shoulder impingement syndrome is part of a larger more complex shoulder problem that requires a more detailed understanding and a more aggressive treatment protocol than medication and rest.
Let’s bring in some more opinions.
In November 2019, Dr. Kuldip Singh Dhillon published these observations in the Malaysian Orthopaedic Journal: (6)
- “Subacromial impingement syndrome is a commonly diagnosed disorder of the shoulder. Though this disorder has been known for a long time, it remains a poorly understood entity.”
- Over the years several hypotheses have been put forward to describe the pathogenesis of Subacromial impingement syndrome but no clear explanation has been found. (No one is sure how it develops.) Two mechanisms, the extrinsic and intrinsic mechanisms, have been described for impingement syndrome. The intrinsic mechanism theories which deny the existence of impingement are gaining popularity in recent years.
We have to stop here to give a further explanation. There are two degenerative shoulder problems: Extrinsic and Intrinsic. These are best explained by the symptoms or diagnosis most attributed to them. Let’s bring in an explanation from the Department of Physical Therapy, Virginia Commonwealth University-Medical College of Virginia Campus published in the journal Clinical Biomechanics. (7)
- Extrinsic factors that encroach upon the subacromial space and contribute to bursal side compression of the rotator cuff tendons include anatomical variants of the acromion, alterations in scapular or humeral kinematics (how much your upper arm bone is floating around), postural abnormalities (thoracic and cervical spine have been suggested in other research), rotator cuff and scapular muscle performance deficits, and decreased extensibility of pectoralis minor or posterior shoulder.
- Intrinsic factors that contribute to rotator cuff tendon degradation include alterations in biology (diseases), mechanical properties (shoulder not working right), morphology (degenerative changes), and vascularity (problem with blood flow). The varied nature of these mechanisms indicates that rotator cuff tendinopathy is not a homogenous entity, and thus may require different treatment interventions. (If the patient has high blood pressure or diabetes, that needs to be part of the treatment plan.
- Treatment aimed at addressing mechanistic factors appears to be beneficial for patients with rotator cuff tendinopathy, however, not for all patients.
Simply, Extrinsic factors deal more with mechanical breakdown and intrinsic factors deal more with co-morbidities, and other diseases that may impact the shoulder’s ability to heal.
“Surgical treatment should have no role in the treatment of such (Subacromial impingement syndrome) patients”
Let’s return to Dr. Kuldip Singh Dhillon’s paper:
- “The various shoulder tests used to diagnose Subacromial impingement syndrome have low specificity with an average of about 50% (accuracy).
- “Several randomized controlled trials have shown that the outcome of treatment of Subacromial impingement syndrome by surgery is no better than conservative treatment. Physiotherapy alone can provide good outcomes that are comparable to that achieved with surgery without the costs and complications associated with surgery. Since decompression with surgery does not provide any additional benefits as compared to conservative treatment for patients with Subacromial impingement syndrome, the impingement theory has become antiquated and surgical treatment should have no role in the treatment of such patients. There are calls by some practitioners to abandon the term impingement syndrome and rename it as anterolateral shoulder pain syndrome. It appears that Subacromial impingement syndrome is a medical myth. There are others who called Subacromial impingement syndrome a clinical illusion.”
Here is what doctors at one of Germany’s leading sports university hospitals, the Technical University of Munich writing in the German language journal Der Orthopäde (Orthopedics) reported (8):
- Isolated impingement syndrome of the shoulder is the most common diagnosis in shoulder disorders and is of high relevance in orthopedic sports medicine.
- In fact, impingement of the shoulder is not the diagnosis but rather a symptom of functional or even structural shoulder damage.
- (We call this shoulder instability, the excessive motion of the shoulder due to weakened and damaged ligaments, that allow the soft tissue of the rotator cuff to be pinched, caught, or impinged upon by the bones of the shoulder).
- Detailed knowledge about the different types of impingement and the underlying causes is essential to provide adequate treatment.
- Primarily, impingement of the shoulder should be treated non-operatively.
This brings us to the latest research on surgery for shoulder impingement.
Arthroscopic treatment should no longer be offered to people with subacromial impingement.
In August 2022, researchers from Monash University in Finland published their opinion in the medical journal Arthroscopy (19) that arthroscopic treatment should no longer be offered to people with subacromial impingement. This is what they wrote: “Arthroscopic treatment should no longer be offered to people with subacromial impingement. In many people, subacromial impingement (or subacromial pain syndrome) is self-limiting and may not require any specific treatment. This is evident by the fact that almost 50% of people with new-onset shoulder pain consult their primary care doctor only once. The best-available evidence from randomized controlled trials indicates that glucocorticoid injection provides rapid, modest, short-term pain relief. Exercise therapy has also been found to provide no added benefit over glucocorticoid injection. Subacromial decompression (bursectomy and acromioplasty) for subacromial pain syndrome provides no important benefit on pain, function, or health-related quality of life. Acromioplasty does not improve the outcomes of rotator cuff repair.”
Many doctors disagree and say surgery does have its place after failed conservative care treatments
The debate over the benefits of shoulder impingement surgery continued to be played out in the August 2022 issue of Arthroscopy (x). In this paper, doctors from Massachusetts General Hospital, the University of California San Diego, the Mayo Clinic, and Rush University Medical Center published findings combing data from 35 studies and 3,643 shoulders (42% female, average patient age 50).
Here are the paper’s highlights:
- Arthroscopic decompression with acromioplasty ranked much greater than arthroscopic decompression alone for pain relief and patient-reported outcome measures improvement, but the difference in absolute patient-reported outcome measures was not statistically significant.
- Corticosteroid injection alone demonstrated inferior outcomes in pain, patient-reported outcome measures, and range of motion with low cumulative rankings.
- Physical therapy with Corticosteroid injection demonstrated moderate-to-excellent clinical improvement across pain, patient-reported outcome measures, and range of motion whereas PT alone demonstrated an excellent range of motion and low-moderate outcomes in pain and patient-reported outcome measures domains.
- PT with nonsteroidal anti-inflammatory drugs or alternative therapies ranked highly for patient-reported outcome measures and moderate for pain and range of motion domains. Finally, platelet-rich plasma injections demonstrated moderate outcomes for pain, forward flexion, and abduction with very low-ranking outcomes for patient-reported outcome measures and external rotation.
Conclusions: “Arthroscopic decompression with acromioplasty and PT demonstrated superior outcomes whereas Corticosteroid injection alone demonstrated poor outcomes in in pain, patient-reported outcome measures, and range of motion. For patients with significant symptoms, the authors recommend PT with CSI as a first-line treatment, followed by acromioplasty and PT if conservative treatment fails. For patients with symptoms limited to 1 to 2 domains (pain and or low, patient-reported outcome measures, and/or low range of motion), the authors recommend a shared decision-making approach focusing on treatment rankings within domains pertinent to individual patient symptomatology.”
More research: Impingement of the shoulder cannot be treated as an isolated injury. You need to treat the whole shoulder.
The controversy over managing Shoulder Impingement Syndrome as an isolated problem or a part of systematic shoulder failure was also the subject of doctors in the United Kingdom who published their research in the Indian Journal of Orthopaedics (9).
Here are the bullet points of that research:
- Subacromial impingement syndrome is a syndrome that encompasses a spectrum of subacromial pathologies ranging from bursitis, rotator cuff tendinosis, and partial tears leading up to full-thickness tear of the rotator cuff. (Comment – in black and white, Subacromial impingement syndrome IS part of a bigger generative shoulder problem).
- Research suggests that the impingement process can be broken down into three distinct stages.
- Stage I of the process is defined as edema and hemorrhage of the subacromial bursa, often in patients under the age of 25 years.
- Stage II impingement is when irreversible changes have developed and are represented by tendinitis and fibrosis of the rotator cuff tendon, seen in patients between the age of 25 and 40 years.
- Stage III impingement is said to have occurred when there are chronic changes such as rotator cuff tears, common in patients over the age of 40 years.
- There is an ongoing debate on how impingement begins and how it creates rotator cuff tears, but it is likely to be multifactorial.
Treating Shoulder impingement syndrome as part of a problem of degenerative shoulder disease
One of our main treatment philosophies is that you cannot treat spinal or joint problems in isolation. This includes problems with the shoulder. To treat shoulder impingement syndrome, you need to treat the whole shoulder.
As we discussed above, NSAIDs, painkillers, and cortisone are limited in their ability to help long-term and in fact can be seen as detrimental to the patient. What else then is available? Typically physical therapy and surgery.
Research: Surgery for shoulder impingement syndrome is “useless.” Is it really?
This is from a press release issued by the University of Helsinki upon the publication of a new study from the University’s researchers in the July 19, 2018 edition of the British Medical Journal. (10)
“In a landmark study published this week in the British Medical Journal, (our) researchers show that one of the most common surgical procedures in the Western world is probably unnecessary.”
“Keyhole (arthroscopic) surgeries of the shoulder are useless for patients with “shoulder impingement”, the most common diagnosis in patients with shoulder pain.”
“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.”(11)
A second report from doctors at Monash University in Melbourne was published in January 2019 in The Cochrane Database of Systematic Reviews. (12) Here are the findings of the researchers
- “The data in (our) review do not support the use of subacromial decompression in the treatment of rotator cuff disease manifest as painful shoulder impingement. High-certainty evidence shows that subacromial decompression does not provide clinically important benefits over a placebo in pain, function, or health-related quality of life. “
Surgery and Physical Therapy or Physical Therapy alone for shoulder impingement syndrome? Which Benefits patients most? Surgeons say they can’t tell.
In May 2019, in the medical journal Public Library of Science One,(13) researchers from Western University in London, Ontario examined patients who had:
- a shoulder impingement syndrome surgery and physical therapy and
- a “placebo” or fake shoulder impingement syndrome surgery and physical therapy,
to see if the “real” surgery plus physical therapy was more beneficial to patients than physical therapy alone.
This is what the researchers wrote:
“We synthesized very-low to moderate-quality evidence and continue to suggest that physiotherapy intervention programs (with exercise component) be used as the main and first treatment approach for the treatment of patients with shoulder impingement. Ultimately, the surgical option may be considered, however, it is important to note (despite the very low to moderate-quality evidence), the lack of clinically important benefits of surgery over physiotherapy (mainly exercise). In addition, patient goals, values, and shared decision-making need to be incorporated when discussing treatment options for patients with subacromial pain syndrome.”
“The effects of surgery plus physiotherapy compared to physiotherapy alone on improving pain and function are too small to be clinically important at 3 months, 6 months, 1 year, 2 years, 5 years, and more than 10 years follow up.
Similarly, surgery plus physiotherapy vs placebo (surgery) plus physiotherapy comparison demonstrated no clinically important differences in terms of improving pain or function at 3 months, 6-months, 1 year, 2 years follow up.”
Is surgery useless? No better than physical therapy alone? Then what type of treatments can I get?
Arthroscopic shoulder impingement surgery shaves down the bone of the acromion to give the rotator tendons more room to move about pain-free. We now see that this is a useless surgery in the long run. Rotator cuff tendon surgery then may be recommended for lack of anything better than conservative treatments including pain medication, anti-inflammatory medication, physical therapy and exercise did not offer a positive response.
We feel that someone suffering from impingement syndrome should seek a consultation with a Prolotherapist for a non-surgical regenerative medicine consultation before jumping into rotator cuff surgery.
In this section of our article, we will look at research that supports the use of regenerative medicine to rebuild the soft internal structures of the shoulder. Here we will look at Prolotherapy, the injections of simple dextrose or sugar into the shoulder as well as explore the use of your blood platelets in Platelet Rich Plasma therapy.
These techniques have been shown valuable in the treatment of many types of shoulder problems. In our clinics, we use these treatments to rebuild, repair, strengthen, and stabilize the shoulder by repairing damaged shoulder ligaments and tendons.
The patient had a rounded shoulder posture causing impingement.
In this video, Dr. Hutcheson describes a patient case where chiropractic manipulation and exercise help a patient with shoulder impingement
The transcript summary and explanatory notes are below
Rounded shoulder posture
The patient had a rounded shoulder posture. His head was in a forward position caused by poor posture and rounding of the upper spine and shoulders.
Dr. Hutcheson explains helping this patient: (1:40 of the video)
- The first thing I did was to demonstrate to the patient how his rounded forward posture worsened his shoulder problems. I did this by making myself the model and distorting my posture to match his. This made it very difficult to raise my arm up over my shoulder. As mentioned he is a tennis player who could not do an overhead serve.
- When I corrected my posture I could raise my arm over my head.
- To help this patient we did some specialized instrument-based adjustments and I taught him a few exercises to help keep his body in a more upright position. In this patient, after one visit he was feeling about 70% better. (This may not be typical of all patients depending on the degree of their problems).
An overview of Prolotherapy injections for the treatment of shoulder impingement syndrome: Caring Medical research
Prolotherapy is an in-office injection treatment of simple dextrose or sugar. The science and research on Prolotherapy can be found on our Prolotherapy research page.
Is Prolotherapy like cortisone?
- The difference between Prolotherapy and Cortisone is extensive.
- Cortisone when injected into the joint can successfully mask pain. Many people have very successful treatments with Cortisone. We typically see patients who have a long history of Cortisone injections and these injections are no longer effective for them.
- Over the years we have seen many patients who have received corticosteroid (cortisone) injections for joint pain. Unfortunately for many, excessive cortisone treatments lead to a worsening of chronic pain. Again, while some people do benefit from cortisone in the short term – the evidence however points to cortisone causing more problems than it helps.
Prolotherapy is a regenerative injection treatment used to treat shoulder pain by repairing damaged and weakened ligaments and tendons.
- Prolotherapy is considered a viable alternative to surgery, and as an option to pain medications, cortisone, and other steroidal injections.
- The Prolotherapy procedure is considered a safe, affordable option that allows the patient to keep working and/or training during treatment.
In 2009, a Caring Medical research team led by Ross Hauser, MD studied 94 patients with an average of 53 months of unresolved shoulder pain that were treated quarterly with Prolotherapy. The results of this study, published in the Journal of Prolotherapy (14) showed that patients had a statistically significant decline in their level of pain, stiffness, and crunching sensations (crepitation) with Prolotherapy, including the 39% of patients who were told by their medical doctors that there were no other treatment options for their pain and the twenty-one percent who were told that surgery was their only option.
- Over 82% of all patients experienced improvements in sleep, exercise ability, anxiety, depression, and overall disability with Prolotherapy. Ninety-seven percent of patients received pain relief with Prolotherapy.
As mentioned above, in our clinics we treat the problem of shoulder impingement as a problem of the whole shoulder. This study marked its results in improvements in overall shoulder health.
Other researchers specifically targeted Prolotherapy’s effectiveness in treating shoulder impingement
In 2013, a presentation (15) at the American College of Rheumatology’s annual meeting by Turkish researchers offered these results:
- In this single-center, randomized placebo-controlled, single-blind, prospective study, 80 patients with chronic shoulder impingement syndrome received two dextrose injections in the affected shoulder at two weeks intervals.
- The patients were randomly assigned into two therapy groups, either dextrose or other control (lidocaine) groups. The injections were repeated two times with two weeks between injections.
- Clinical assessments included measurement of range of motion (ROM), pain assessment, shoulder functions, and daily living activities. Magnetic resonance imaging (MRI) evaluation was conducted before the first injection and compared with MRIs taken again on the third month following the second injection.
- There were no adverse events reported. The study demonstrated significant improvements in pain and function scores in both injection groups, Prolotherapy, and lidocaine.
- Shoulder flexion, abduction, and internal and external rotations showed significant improvements in both groups in the first 3 months. However, while the range of shoulder flexion did not improve in the control group during the last three months, this range of motion continued to improve significantly in the treatment group over the same period.
Platelet Rich Plasma Therapy (PRP) and shoulder impingement
In this video, a general demonstration of Prolotherapy and PRP treatment is given for a patient with repeated shoulder dislocations.
People get confused with PRP treatment because they think it is “just like cortisone, only safer.” PRP is NOT just like cortisone. Cortisone has an immediate pain-reducing effect for many people, but not all because it is reducing pain brought on by chronic inflammation. Nothing is being healed. PRP brings healing through inflammation. When tissue is repaired, the inflammation goes away.
Danielle R. Steilen-Matias, MMS, PA-C narrates the video and is the practitioner giving the treatment:
- PRP or Platelet Rich Plasma treatment takes your blood, like going for a blood test, and re-introduces the concentrated blood platelets and growth and healing factors from your blood into the shoulder. The treatment is explained further below.
- In the shoulder treatment, I treat all aspects of the shoulder including the ligament and tendon injections to cover the whole shoulder.
- The patient in this video is not sedated in any way. Most patients tolerate the injections very well. The treatment goes quickly. However, we do make all patients comfortable including sedation if needed.
- This patient in particular comes to us for a history of repeated shoulder dislocations. His MRI findings showed multiple labral tears and rotator cuff problems.
- The patient complained of shoulder instability typical of the ligament and tendon damage multiple dislocations can do.
- With the patient laying down, treatment continues to the anterior or front of the shoulder. The rotator cuff insertions, the anterior joint capsule, and the glenohumeral ligaments are treated.
- PRP is introduced into the treatment and injected into the front of the shoulder. PRP is a form of Prolotherapy where we take concentrated cells and platelets from the patient’s blood and inject that back into the joint. It is a more aggressive form of Prolotherapy and we typically use it for someone that has had a labral tear, shoulder osteoarthritis, and cartilage lesions.
- PRP is injected into the shoulder joint and the remaining solution is injected into the surrounding ligaments in this case it was in his anterior shoulder attachments to address the chronic dislocations.
Before we get to the research, it is important to realize that we offer a very comprehensive PRP treatment, not a single one-time injection. In much of the research on PRP, there is a one or two-time treatment and that is the measurement of success. In our patients, we rarely find that one or two treatments can reverse years of degenerative damage such as is found in shoulder impingement. The video above shows our comprehensive program of PRP and Prolotherapy together. We do not offer PRP without Prolotherapy. The two work together to bring about stability and repair. Prolotherapy is the consistent missing component of PRP research.
A December 2019 (16) study from medical university researchers in Brazil suggests that in a head-to-head, one-shot vs. one-shot competition, PRP would be a better treatment option for patients. Here is what they said: “The efficacy of PRP as a therapeutic modality still needs to be better clarified, but its characteristics make it a promising therapy in the treatment of rotator cuff tendinopathy. Corticosteroids, although well studied when their efficacy and side effects, remain a rising concern in their chronic use in clinical practice.”
Doctors in the Czech Republic thought that PRP injections could help people with Shoulder Impingement Syndrome. They thought that it would take three injections, given one week apart, to achieve the desired results. They also wanted to see how these three PRP injections did against a single injection of cortisone. Their findings were reported to the Czech society for orthopedics of traumatology. (17)
- After treatment patients were followed at 6 weeks, 3 months, and 6 months. Based on follow-up, the researchers concluded that platelet-rich plasma administered through a series of 3 injections applied in the subacromial space in patients with shoulder impingement syndrome has positive effects on daily activities superior to cortisone.
In May 2017, researchers published a study “Treatment of Subacromial Impingement Syndrome: Platelet-Rich Plasma or Exercise Therapy? A Randomized Control Trial.” (18) In this study published in the journal Orthopaedic journal of sports medicine, doctors looked at patients who would receive exercise therapy or PRP injections for their Subacromial Impingement Syndrome.
In this study, the patients who received PRP had two treatments, two injections at each treatment. The first treatment was at the onset of their research participation and the second injection, was one month later.
Here are some of the learning points of this research:
- “The main finding of the present research was that the shoulder pain emanating from Subacromial Impingement Syndrome can be reduced through either PRP injection or exercise therapy. At the final follow-up, there was no significant difference between the 2 groups in our primary outcome measure (pain), but the exercise therapy group had significantly higher Western Ontario Rotator Cuff (Rotator Cuff motion) scores and abduction ROM (the ability to move your arm away from your body).”
- Despite other studies showing limited or no benefit of PRP, “In the current study, 2 PRP injections were given 30 days apart. The injections were made both into areas of tendinopathy and into the bursa. The continued clinical improvement seen in our patients could be related to the difference in PRP technique.”
The researchers suggest that they were able to achieve better results because the patients were injected twice in the same visit as opposed to once.
- According to the researchers: “This study showed that both PRP injection and exercise therapy can significantly reduce pain and improve shoulder ROM and functionality in patients with Subacromial Impingement Syndrome, with these beneficial effects lasting for 6 months. In spite of our hypothesis, exercise therapy was found to be more effective than the other treatment option until 3 months after initiation. Moreover, neither treatment choice significantly improved shoulder muscle force. What is more, even though the treatments resulted in clinical improvement, MRI findings did not change.”
Caring Medical Research
Ross Hauser, MD discusses the Prolotherapy treatment results that were published a few years ago as part of our article series on the use of Hackett-Hemwall dextrose Prolotherapy, as well as shows a treatment demonstration from a Prolotherapy symposium he taught in 2021
Summary and contact us. Can we help you?
In our office, we stimulate the soft tissue of the shoulder to repair with Prolotherapy injections to the ligaments and tendinous insertions of the rotator cuff and deltoid. Prolotherapy, in combination with Platelet Rich Plasma injections and gradual re-strengthening of the rotator cuff muscles, gives an excellent chance for a full recovery.
Our treatments can get rid of the impingement by stabilizing the acromioclavicular (smaller shoulder joint) or the glenohumeral joint (larger shoulder joint). The excessive motion that was pinching the tendon no longer occurs, because the joint is stabilized. The excessive motion is gone, the pinching and symptoms are gone, and over time the bone spur will be reabsorbed by the body.
We hope you found this article informative and that it helped answer many of the questions you may have surrounding your shoulder problems. If you would like to get more information specific to your challenges please email us: Get help and information from our Caring Medical staff
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This article was updated September 27, 2022