If drug therapy and physical therapy are unsuccessful and/or symptoms persist for more than 8-10 weeks, surgical therapy should be considered. Likewise, if the discomfort is occupational.
Note: At a younger age (< 40 years), a traumatic rotator cuff rupture should be promptly reconstructed surgically before retraction (“pulling back”) of the tendon occurs.
The following procedure is used for outlet impingement:
- Neer acromioplasty (“Neer plasty”) – open or endoscopic straightening of the (pathologically) concave lower surface of the acromion in major ruptures – depending on the situation, the procedure includes:
- Bursectomy (removal of the bursa).
- Resection (removal) of the coracoacromial ligament (triangular-shaped ligament located between the bony process of the scapula (shoulder blade) and the bony prominence of the scapula).
- Partial resection (partial removal) of the lower acromion (“subacromial decompression” (SAD)/shoulder decompression).
- Indication: outlet impingement – morphological (“affecting the shape”)/mechanical dysfunction.
- Contraindications: non-outlet impingement – ligamentous (concerning the ligaments) or neuromuscular (“concerning the nerves and the muscles”) conditioned dysfunction.
Surgery expands the subacromial space so that the tendons are no longer pinched.
Rotator cuff surgery is followed by four to six weeks of immobilization of the arm using an arm sling. In a small study with a relatively short follow-up period, it was shown six months later that when an arm sling was not used postoperatively (= sling-free rehab), mobility was greater and pain was somewhat less.
In patients with small to moderate rotator cuff rupture, 10-year outcomes were significantly better for patients undergoing primary surgery than for patients undergoing physical therapy alone.
Additional notes
- CSAW (“Can Shoulder Arthroscopy Work?”) study: subacromial shoulder pain cannot be relieved more by decompression surgery than by a sham procedure involving only arthroscopy but no debridement.Conclusion:
- Observe and wait (up to 12 months).
- Prescription of physiotherapy (conservative approach should save surgery in the long term in up to 80% of patients).
- Subacromial decompression as a last option.
For tendinosis calcarea (tendon calcification; calcific shoulder) see below of the disease of the same name.
