Bloodletting for pneumonia, bed rest for low back pain. Is subacromial decompression another medical illusion? The case for rotator cuff rehabilitation

Abstract Neer1,2 published a clinical commentary describing a condition known as subacromial impingement syndrome where abrasion from the overlying acromion onto the rotator cuff results in 95% of all rotator cuff pathology. Subacromial impingement syndrome has become one of the most commonly diagnosed musculoskeletal conditions involving the shoulder and subacromial decompression (SAD), a procedure to remove the abrasion, one of the most common orthopaedic surgical procedures. Between 2001 to 2010 the number of SADs increased by 746% in England, United Kingdom3. Many physiotherapists and other health professional have embraced the SIS model describing how poor upper body posture, colloquially termed a forward head posture, is associated with an increase in the thoracic kyphosis with an imbalance of the shoulder girdle muscles. This results in an abnormal scapular posture (anterior tilt and downward rotation) resulting in impingement and RC pathology. In addition there has been a substantial increase in surgery to repair partial and full thickness tears involving the RC. The cost of these surgical procedures to healthcare providers and the individual is substantial. In addition, the increase is of concern, as research has repeatedly demonstrated no additional benefit from surgery when compared to a graduated exercise program for; subacromial impingement syndrome, as well as atraumatic partial and full thickness rotator cuff tears. Although there is a belief that the symptoms (pain and loss of shoulder function) relate to the shape of the acromion, size of the rotator cuff tear; research evidence does not support these contentions, and symptoms appear to be related more to psycho-social factors, such as level of education, as well as concomitant co-morbidities. These and other issues such as; the relationship to posture and symptoms, as well as our ability to make a definitive diagnosis on which to base management have also been substantially challenged4-8. History has demonstrated that bloodletting for pneumonia, prolonged bed rest for low back pain are clinical illusions and current evidence supports the contention that this may also be the case for subacromial decompressions and repairs of atraumatic rotator cuff tears. It is essential for healthcare professionals to be mindful not to over emphasis the relationship between structural failure and symptoms. These issues will be presented in the lecture. References: 1. Neer CS, 2nd. Anterior acromioplasty for the chronic impingement syndrome in the shoulder: a preliminary report. J Bone Joint Surg Am. 1972;54(1):41-50. 2. Neer CS, 2nd. Impingement lesions. Clin Orthop Relat Res. 1983(173):70-7. 3. Judge A, Murphy RJ, Maxwell R, Arden NK, Carr AJ. Temporal trends and geographical variation in the use of subacromial decompression and rotator cuff repair of the shoulder in England. Bone Joint J. 2014;96-B(1):70-4. 4. Lewis J, McCreesh K, Roy JS, Ginn K. Rotator Cuff Tendinopathy: Navigating the Diagnosis-Management Conundrum. J Orthop Sports Phys Ther. 2015:1-43. 5. Lewis JS. Rotator cuff tendinopathy/subacromial impingement syndrome: is it time for a new method of assessment? British Journal of Sports Medicine.2009;43(4):259- 64. 6. Lewis JS. Subacromial impingement syndrome: A musculoskeletal condition or a clinical illusion? Physical Therapy Review. 2011;16(5):388-98. 7. Lewis JS. Bloodletting for pneumonia, prolonged bed rest for low back pain, is subacromial decompression another clinical illusion? British Journal of Sports Medicine. 2015;49(5):280-1. 8. Ratcliffe E, Pickering S, McLean S, Lewis J. Is there a relationship between subacromial impingement syndrome and scapular orientation? A systematic review. British Journal of Sports Medicine. 2014;48(16):1251-6. 9. McCreesh, K., Donnelly, A., & Lewis, J. (2014). Immediate Response Of The Supraspinatus Tendon To Loading In Rotator Cuff Tendinopathy. . Br J Sports Med, 48, A42-A43. doi:doi:10.1136/bjsports-2014-094114.65 Podcast: http://physioedge.com.au/shoulderpodcast