Helping patients make decisions about shoulder surgery

[AJ Lievre]

This past weekend we had some good discussions on the physical therapy management of a number of shoulder related health conditions. While we touched on surgical intervention, we did not explore with depth the complexity associated with the various factors leading to surgical intervention, or the post-operative considerations following shoulder surgery. For this discussion, let’s talk about surgery. Below are some ‘conversation starters’ that could help us understand the role of surgery in the management of people with orthopedic shoulder problems. We can touch on each of the items below, but to start, pick one or two topics that you have a harder time answering and let’s chat.

– What are the pros associated with shoulder surgery? We tend to focus on the risks (e.g. infection, post-operative stiffness, subsequent procedures, etc) but there are a number of reasons why someone would have surgery of their shoulder – what are some of them?

– Sometimes we forget that as part of a healthcare ‘team’ we actually work together with other professions – not competitively against them. What are some of your biases against surgery? Let’s be honest and put out your biases, then, come up with a few specific phrases you could use in patient interactions to recommend surgical consults without your biases coming through.

– We spoke to the lack of efficacy of a variety of surgeries for shoulder impingement. What shoulder conditions have evidence to support the use of surgical intervention? Please come up with 1-2 conditions, and offer a couple citations to support your answer.

– Critical appraisal of evidence is essential to quality clinical practice. What are some of the challenges with research trials investigating surgery versus other interventions?

– What role should diagnostic imaging have in surgical management of shoulder pathology? There are a lot of times where we see abnormality of imaging in asymptomatic individuals – when does imaging become relevant?

Here are a couple of additional articles that don’t necessarily answer any of the above questions, but may be relevant resources:

https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2757376

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3262185/pdf/JOBOJOS943227.pdf

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6260082/pdf/abjs-476-810.pdf

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– What are the pros associated with shoulder surgery? We tend to focus on the risks (e.g. infection, post-operative stiffness, subsequent procedures, etc) but there are a number of reasons why someone would have surgery of their shoulder – what are some of them?

Shoulder surgery offers a range of benefits that can significantly improve a patient’s quality of life. It is primarily sought for pain relief, addressing chronic or severe shoulder pain caused by conditions like rotator cuff tears, labral tears, or arthritis. Surgery can also enhance shoulder functionality, improve range of motion, and prevent further joint damage. Correcting structural abnormalities and ensuring a faster recovery are additional advantages. Many shoulder surgeries provide long-term relief and contribute to an improved quality of life by allowing patients to engage in daily activities and return to sports or work with less discomfort. Importantly, shoulder surgery is tailored to the specific condition and patient, offering a personalized approach to treatment. However, the decision to undergo surgery should be made in consultation with a healthcare professional, considering both the potential benefits and risks.

– We spoke to the lack of efficacy of a variety of surgeries for shoulder impingement. What shoulder conditions have evidence to support the use of surgical intervention? Please come up with 1-2 conditions, and offer a couple citations to support your answer.

Rotator cuff tears, especially full-thickness tears, are a common condition that may require surgical intervention. The evidence for the effectiveness of surgery in treating rotator cuff tears is well-documented. A systematic review and meta-analysis by Moosmayer et al. published in the Journal of Bone and Joint Surgery in 2017 found that surgical repair of symptomatic full-thickness rotator cuff tears was associated with significantly better outcomes in terms of pain relief and functional improvement compared to non-surgical treatment.

Reference: Moosmayer, S., Lund, G., Seljom, U. S., Haldorsen, B., Svege, I. C., Hennig, T., … & Brox, J. I. (2017). Tendon repair compared with physiotherapy in the treatment of rotator cuff tears: a randomized controlled study in 103 cases with a five-year follow-up. JBJS, 99(2), 83-92.

Glenohumeral instability, which includes conditions like recurrent shoulder dislocations or subluxations, can often benefit from surgical intervention, particularly for cases with frequent episodes of instability that significantly impact a patient’s quality of life. A study by Hovelius et al. published in the Journal of Bone and Joint Surgery in 2008 demonstrated that surgical stabilization of the shoulder joint was effective in reducing the recurrence of dislocations in young, active individuals.

Reference: Hovelius, L., Sandström, B., Olofsson, A., Svensson, O., Rahme, H., & Akermark, C. (2008). Nonoperative treatment of primary anterior shoulder dislocation in patients forty years of age and younger: a prospective twenty-five-year follow-up. JBJS, 90(5), 945-952.

– What role should diagnostic imaging have in surgical management of shoulder pathology? There are a lot of times where we see abnormality of imaging in asymptomatic individuals – when does imaging become relevant?

The role of diagnostic imaging in the surgical management of shoulder pathology is essential but should be considered in the context of a comprehensive clinical evaluation. Imaging is a valuable tool for identifying structural abnormalities, confirming a diagnosis, assessing the extent of the pathology, and guiding treatment decisions. However, it should not be the sole determinant for surgery.

As for the concern about asymptomatic individuals showing abnormalities on imaging, this is indeed a common occurrence. Many people, especially as they age, may have shoulder abnormalities that do not cause symptoms or limit their function. This phenomenon is referred to as “incidental findings.” The relevance of imaging in such cases comes down to whether the imaging findings correlate with the patient’s clinical symptoms.

Imaging becomes relevant when the clinical presentation and physical examination findings align with the imaging findings. In other words, when a patient has symptoms that are consistent with the abnormalities seen on imaging, surgery may be considered. However, if an asymptomatic individual has abnormal findings on imaging, surgery is typically not indicated. The clinical evaluation and patient’s symptoms should guide the decision for surgical intervention, and imaging serves as a supporting tool to confirm and assess the condition.

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