Clinical Reasoning Around 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

[ebusch19]

The questions that I picked to answer are below:
– 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.

When thinking about my biases against surgery, I realized that I don’t have very strong opinions or biases for shoulder surgeries compared to surgeries for the low back or for the knee. In school we talked a lot about evidence for knee surgeries that questioned their effectiveness when compared to physical therapy or sham surgeries. There is even more evidence coming out now for treating ACL injuries conservatively rather than performing surgery. Jain et al. mentioned in their discussion that there are a lot more RCTs for knee surgeries that looked at their effectiveness compared to shoulder surgeries and related that back to why there was more of an increase in shoulder surgeries compared to knee surgeries over the past several years1. Similarly with surgeries for the low back, and also from prior experience with patients I worked with where the surgery did not help their pain or it ended up coming back a year later. I think from my previous knowledge of research (or lack thereof) and lack of experience working with a lot of post op shoulder surgery patients, I don’t have a very strong bias against pts having surgery for their shoulder.
At this point, starting off as a new clinician, it’s hard for me to say/lack the confidence to know whether a surgery would be beneficial for the patient or not. In regards to the first part of the question, I agree that we often do forget that we are part of a healthcare team working with the patients doctors, and even more so maybe for newer clinicians or PTs working in private practice clinics where they don’t have the direct contact/communication with their doctors. Conservative treatment for at least 4-6 weeks is always a good option and I have seen a lot of doctors doing that now before determining if surgery might be an option. I know patients also want to avoid surgery the best they can so having that conversation with them if they are not doing well with conservative management is hard, and I do not have much experience with that. Two phrases that I came up with to recommend surgical consult are below:
– After working with someone for 4-6 weeks and not seeing improvements: I recommend scheduling an appointment with your doctor for a surgical consult to see if there is another option to address the pain that you’re experiencing and to help improve your function so that you can get back to doing…
– For someone at initial evaluation or earlier on: Let’s work together for 4-6 weeks to improve your strength, ROM, etc. and then consider a surgical consult if we are not seeing improvements in (pain, what they are limited with, etc.) by then. Either way, if surgery is recommended, working on improving your strength prior to has shown to help improve outcomes afterwards.

– 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?

It depends? I think for patients with more traumatic injuries, or for patients who are younger, imaging may be more relevant earlier on for surgical management if they are presenting with significant loss in function, ROM, strength, swelling, neural symptoms, etc. For older patients or less traumatic injuries, who do not present with any red flags, I think working conservatively for at least 4-6 weeks should be done first before considering further imaging if they are not progressing well. This question made me think about a patient I recently evaluated who is in his 60s and came in for R shoulder pain. He had a prior RTC repair several years ago and the patient really wanted new imaging of his shoulder. They did another MRI which found a complete tear and retraction of his supraspinatus tendon and his infraspinatus tendon, among other findings that were chronic. His doctor referred him to PT anyways and mentioned that he won’t do surgery since the tendon has retracted and due to the chronicity of the injury. The imaging helped me make sense of his pain and impairments with strength in ROM, but overall, we have been able to make improvements so far with ROM over the past 2 weeks and would have been able to do that without the imaging. I think sometimes it’s hard to avoid imaging when the patients feel like they need to have it done to be reassured/know what’s going on which leads to seeing abnormal findings that may or may not be contributing to their pain, and then potentially leading to surgery that may or may not be needed.

Interested to hear what others have to say!

References:
1. NB, Jain, Peterson E, Ayers GD, Song A, Kuhn JE. US Geographical Variation in Rates of Shoulder and Knee Arthroscopy and Association With Orthopedist Density. JAMA Network Open. 2019;2(12):e1917315. doi:10.1001/jamanetworkopen.2019.17315

[cmocarroll]

Hi Emily,

Thanks for you insightful post! When I read your answer to the first question, I felt like I had the same thoughts. I definitely feel like I have more biases around LE and spine surgeries mostly because I have treated more individuals with impairments in those regions and feel like I know more about those surgeries. Treating the shoulder/understanding implications for surgery/surgical outcomes is definitely one of my knowledge gaps. I think I would approach patient interactions regarding surgery the same way. Plainly stating that they may want to consult with a surgeon due to the lack of progress/other objective data. I think keeping it objective would help in those situations. Depending on my rapport with the patient, I think I would also approach any questions regarding surgery very honestly and cite facts that I do know as well as indicate when I simply do not know or when I do not have a great answer to their concerns.

[cmocarroll]

The first question I’ll respond to is: 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.

(I inadvertently touched on this question as well: Critical appraisal of evidence is essential to quality clinical practice. What are some of the challenges with research trials investigating surgery versus other interventions?)

I chose this question knowing that it would be difficult for me to answer. My first thought was that surgical intervention is typically the “go-to” after failure of conservative management. The conditions that I initially thought may benefit from surgery included advanced shoulder OA as well as massive rotator cuff tears/tears with OA. I did not expect it to be that difficult to find evidence supporting these procedures, but through my search I found a lot of conflicting evidence. One systematic review by Petrillo et al found that reverse shoulder arthroplasty restores ROM and improves shoulder function in patients with massive RTC tears or cuff tear arthropathy, but there is a high level of complications and lack of evidence for understanding the limitations/benefits of this treatment. Another systematic review following up from a previous review in 2010 that focused on surgical management for advanced shoulder osteoarthritis (Craig 2020) found very low level evidence for greater improvement in pain and functional ability with TSR compared to hemiarthroplasty. Both of these studies emphasized the need for more research, especially research comparing surgical intervention to sham and non-surgical management and research studies with longer follow-up timeframes. I think the lack of evidence comparing surgical interventions to non-surgical management makes sharing advice with patients and patients choosing surgical intervention quite a difficult task. Most of the time I think that patients expectations of surgical procedures relates to their personal experiences. I’ve had multiple patients name a friend or family member who had a similar surgery and base their choice partially from hearing that experience.

Craig RS, Goodier H, Singh JA, Hopewell S, Rees JL. Shoulder replacement surgery for osteoarthritis and rotator cuff tear arthropathy. Cochrane Database of Systematic Reviews 2020, Issue 4. Art. No.: CD012879. DOI: 10.1002/14651858.CD012879.pub2. Accessed 30 October 2022.

Petrillo, S., Longo, U.G., Papalia, R. et al. Reverse shoulder arthroplasty for massive irreparable rotator cuff tears and cuff tear arthropathy: a systematic review. Musculoskelet Surg 101, 105–112 (2017). https://doi-org.ezp.slu.edu/10.1007/s12306-017-0474-z

The second question I will address is: 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?

I think that imaging becomes relevant when it matches objective findings and correlates with the patients function and pain. Like Emily said, I agree that imaging is important initially for those with traumatic injuries, red flags, etc. I think that knowing what is found on imaging can help patients understand why they are in pain, and as a clinician can further justify treatment, but I also think this needs to be “taken with a grain of salt”. I commonly explain to patients that imaging results do not always match how they feel (small tears but massive amounts of pain). I try to use the imaging results as an avenue for education although this does not always work. Some patients are always going to get caught up on the imaging results and just want their impairments “fixed”. At this point, I think advocating for conservative treatment for the first few months and reassessing after that time is the best way to go.

[iwhitney]

Hey Clare,

Great post! I definitely agree that it can be difficult to decipher what option (surgery vs conservative) may be best for a patient when the evidence is poor or not entirely supportive of one vs another for shoulder pathology. I think you bring up a great point about patient’s personal experiences impacting their decisions. I’ve experienced much of the same and especially within the older populations, I notice they place all their trust in whatever the surgeon says. This I find to be incredibly difficult because of course a surgeon wants to perform surgery, that’s what they do, but how do we counter what they’re saying without seeming entirely contradictory? I think that’s where better research could play a role or being able to phrase your words carefully so a patient understands the multitude of options they have available.
I agree that some patients can get really caught up in their imaging results to the point where it leads to further pain and disability based on their thoughts and behaviors regarding their condition. Like you said, if the imaging matches their clinical presentation, that can be a great tool to lead to better decision making and decreased healthcare utilization. Have you ever utilized the research about asymptomatic imaging when educating patients about their own imaging results? If so, did you feel like it helped their understanding of how the image doesn’t always equal the presentation?

[iwhitney]

I found this week’s discussion topic to be particularly challenging because when I reflect on my clinical experience with shoulder pathologies, I can think of patients where shoulder surgery seemed to help them tremendously, and others where it didn’t improve anything, or perhaps made them feel worse. I think that’s where this topic can be challenging, as it often seems to depend on many factors for whether surgery is the most appropriate option for a patient, and the reasoning behind that can be complex. The first question I decided to answer is: 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?

When I think of the patient’s I’ve seen that have had shoulder surgery, many have either had a traumatic incident that severely limited their function or they had a chronic condition that increased their pain and disability with no success from conservative management (including PT, CSI, PRP, etc.). When I looked to the literature on this topic, I found a lot of articles that analyzed surgical outcomes vs conservative management for anterior shoulder instability. A systematic review and meta-analysis by Hurley et al. (2020) analyzed arthroscopic bankart repair vs conservative management for first-time traumatic anterior shoulder instability.1 They concluded that arthroscopic bankart repair resulted in a 7x lower recurrence rate and higher rate of return to play than conservative management.1 I thought this article definitely challenged some of my own biases as I’ve often found myself leaning towards conservative management as the best first option. It certainly makes sense that a traumatic anterior shoulder dislocation can put an individual at a higher risk for recurrent dislocations, especially in the overhead athlete. In the instance of traumatic anterior shoulder instability in an overhead athlete, I agree that shoulder surgery is the more indicated option vs conservative management due to the demands of the particular sport and high recurrence rates in athletes (up to 100% in some studies).1

In my opinion, other reasons why someone would opt for surgery of their shoulder include: significantly decreased function due to limited ROM, strength, and increased pain, failed conservative management, and inability to perform sport/vocational activities. Despite conservative management being the usual first line of treatment for shoulder OA, one shoulder surgical procedure that is well supported by the literature, when indicated, is total shoulder arthroplasty.2 I think this brings up another good reason why someone would have shoulder surgery; that is, when they have tried conservative measures with minimal to no improvement in pain and disability.

Another topic I found challenging to answer is the question: Critical appraisal of evidence is essential to quality clinical practice. What are some of the challenges with research trials investigating surgery versus other interventions?

Even before I looked at the literature, the first thing that came to my mind was the ethicality of performing some form of sham surgical procedure without actually performing any sort of surgical repair. Due to the invasiveness of shoulder surgery, I find it difficult to imagine how it could be controlled without ethical issues. Considering this dilemma, I found a lot of research that compared surgical interventions to conservative management was often of a lower level evidence and retrospective in nature with a lack of randomization and control group.2-5 Other limitations I found in studies comparing surgical vs conservative management include: risk of bias (how do you choose who gets surgery?), demographic heterogeneity between subjects (poor internal validity), and a lack of long-term follow-up.2-5 Overall, I feel that there will always inherently be some selection bias when comparing surgical vs conservative management, which poses a challenge to the strength of evidence available. However, I feel we can use the evidence that is available, as well as some of the points I alluded to earlier to effectively determine if surgery is truly the best option for our patients. I would love to hear anyone’s thoughts on the potential ways that the challenges for comparing surgical vs conservative management in research could be addressed.

References:

1. Hurley ET, Manjunath AK, Bloom DA, et al. Arthroscopic Bankart Repair Versus Conservative Management for First-Time Traumatic Anterior Shoulder Instability: A Systematic Review and Meta-analysis. Arthro: J Arthro & Rel Surgery. 2020;36(9):2526-2532. doi:10.1016/j.arthro.2020.04.046
2. Pandya J, Johnson T, Low AK. Shoulder replacement for osteoarthritis: A review of surgical management. Maturitas. 2018;108:71-76. doi:10.1016/j.maturitas.2017.11.013
3. Ramme AJ, Robbins CB, Patel KA, Carpenter JE, Bedi A, Gagnier JJ, Miller B, Surgical Versus Nonsurgical Management of Rotator Cuff Tears: A Matched-Pair Analysis. J of Bon & Join Surg. Accessed October 30, 2022. https://oce-ovid-com.suproxy.idm.oclc.org/article/00004623-201910020-00008/HTML
4. Nazari G, MacDermid JC, Bryant D, Athwal GS. The effectiveness of surgical vs conservative interventions on pain and function in patients with shoulder impingement syndrome. A systematic review and meta-analysis. PLoS ONE. 2019;14(5):1-22. doi:10.1371/journal.pone.0216961
5. Alkhatib N, Abdullah ASA, AlNouri M, Ahmad Alzobi OZ, Alkaramany E, Ishibashi Y. Short- and long-term outcomes in Bankart repair vs. conservative treatment for first-time anterior shoulder dislocation: a systematic review and meta-analysis of randomized controlled trials. J Shoul & Elb Surg. 2022;31(8):1751-1762. doi:10.1016/j.jse.2022.02.032

[ebusch19]

Hi Ian,

Great post! I also found the discussion post to be challenging. I have only worked with a few patients post surgery and did not get to follow through with them long-term since I was not the primary person working with them at my clinical. I also agree with your reasons for why someone would opt for surgery and also think age plays a big part in that too.

I’ve always thought about the studies that looked at sham surgeries and the ethicality behind that too, especially with all the increased risks involved with surgery in general. I think it’s interesting that you brought up that you were seeing mostly lower level evidence and retrospective studies that compared surgical intervention vs conservative. The research articles that I looked at that AJ attached also mentioned there was a lack of higher level of evidence compared to studies for the knee and linked that to the increased number of RTC surgeries over the years and less of an increase with knee surgeries. It’s interesting that there are a lot more studies for the knee and not the shoulder.

For potential ways for addressing some of the challenges with the doing surgical vs conservative management is challenging. When I was looking at the research, I saw a lot of retrospective studies as well, along with systematic reviews and meta-analyses. I think offering surgical intervention at the end if the conservative treatment did fail has can be used to help reduce bias with choosing who gets what intervention. But that does pose a challenge with long-term follow-ups if conservative management does fail and the participant wants to get the surgery in the end. I think these challenges are a great thing to think about!

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