Current UK practices in the management of subacromial impingement

Abstract

Background: Controversy presently exists surrounding the management of patients with subacromial impingement. This study aims to highlight current UK practices in the management of these patients. Methods: BESS members were invited to complete a questionnaire and responses were received from 157 consultant shoulder surgeons. Results: Physiotherapy is an integral part of management for 93% of surgeons with a minimum period of 12 weeks being most popular prior to consideration of arthroscopic subacromial decompression. Subacromial steroid injection is used by 95% and 86% repeat this if the patient has failed to respond to a previous injection by the general practioner. From initial presentation, 77% felt there should be at least 3 months of conservative management before proceeding to surgery. Good but transient response to subacromial injection was considered the best predictor of good surgical outcome by 77%. The coracoacromial ligament is fully released by 78%, although there was greater variation in how aggressive surgeons were with acromioplasty. Most (59%) do not include the nontender acromioclavicular joint to any extent in routine acromioplasty. Hospital physiotherapy protocols are used by 63% for postoperative rehabilitation. Conclusions: Variation exists in the management regimes offered to patients with subacromial impingement, but most employ a minimum period of 12 weeks of conservative management incorporating physiotherapy and at least 2 subacromial steriod injections.

The Management of large and massive rotator cuff tears- Current trends amongst UK shoulder surgeons

“…This may in part be due to mass emails such as this survey being treated as spam by NHS servers and therefore not reaching the intended recipients. The response rate is, however, in accordance with other published BESS surveys [14]. Of concern is that some surgeons are offering treatments which may potentially cause harm in the medium and longer term, and there appears to be a poor understanding of the literature in terms of risk factors for recurrence of tear in this category of patient.…”

“…134 complete questionnaires were received (28.5% of the total 470 surgeons surveyed), a comparable response rate to previously published BESS surveys [13][14][15]. Free text comments indicated that whilst some surgeons had rejected patch repair after attempting the procedure in the past, others appeared to be interested in considering this treatment in the future.…”

The incidence of flare reaction and short-term outcome following steroid injection in the shoulder

“…Subsequent to the first two reported studies in the 1950s conducted by Hollander et al 15 and Wrenn et al 16 , on the effects and benefits of corticosteroids in management of intra-articular and soft tissues conditions respectively, their use in injectable forms has gained universal acceptance. 17 The majority of shoulder surgeons use corticosteroid injections as an integral part of their clinical management for patients presenting to them with shoulder pain, 18 and recent national commissioning guidelines . Mean visual analogue scale (VAS) scores for patients who were managed conservatively and discharged successfully by 6 months (blue, circle), patients who were listed for/ had surgery by 6 months for on-going symptoms (green, diamond) and patients whose symptoms became overtly suggestive of cervical spinal pathology (red, square).…”

“…The majority of shoulder surgeons use corticosteroid injections as an integral part of their clinical management for patients presenting to them with shoulder pain, 18 and recent national commissioning guidelines for subacromial impingement and rotator cuff tendonopathy recommend their use in primary care. 6…”

Comparison of Early Results Between Single and Quadruple Injection of Corticosteroid-local Anesthetic in Patients with Subacromial Impingement

“…The initial management of SAS includes rest or activity modification and shoulder exercises (3,4). Local injections and physiotherapy may also aid in healing of the patients (3,(5)(6)(7)(8). Although the pharmacologic mechanism of action is not similar, both corticosteroids and local anesthetics produce similar effects with regard to pain and subsequent improvement in strength and upper limb function (9).…”