You go to the doctor with a complaint of severe shoulder pain. The pain is at the top and side of your shoulder. You tell your doctor that the pain is much worse when you do anything where you have to reach over your head. You tell your doctor that you also have a hard time sleeping at night because the pain is worse when you lay down. You may get an examination and your doctor may look for how much range of motion you have in your shoulder. If you have a lot of pain, you may be recommended to an MRI.
Once the pain is determined to come from subacromial space of the shoulder, that is the area of the rotator cuff tendons and the subacromial bursa, then rotator cuff tendinopathy, (shoulder impingement) is often diagnosed. The impingement occurs when the Acromion’s underside, presses against the rotator cuff tendons causing wear and tear.
If you are a swimmer:
If you are a swimmer, then you may have heard your subacromial shoulder pain called “swimmer’s shoulder.” Swimmer’s shoulder should be thought of as more than an impingement only disorder. Many people I see have a significant problem with shoulder instability leading their shoulder pain to be a multi-cause problem. This was point out by a paper in the journal Current reviews in musculoskeletal medicine.(1)
“Swimmer’s shoulder is the term used to describe the problem of shoulder pain in swimmers. Originally described as supraspinatus tendon impingement under the coracoacromial arch, it is now understood that several different pathologies can cause shoulder pain in competitive swimmers, including subacromial impingement syndrome, overuse and subsequent muscle fatigue, scapular dyskinesis, and laxity and instability.
The cause of shoulder pain in swimmers should be considered multifactorial, including overuse and fatigue of muscles of the shoulder, laxity and instability, and biomechanics of the swimming stroke. Despite the fact that shoulder pain can be clinically present as subacromial impingement, it is typically caused by altered kinematics (non-outlet impingement) due to muscle fatigue or laxity. The role of excessive laxity and muscle imbalance are crucial in the swimmer’s shoulder and should be well understood since they are the primary target of the training and rehabilitation program.”
The surgery to fix this is not effective – surgeons suggest not even offering it
In the late 1980’s and early 1990’s Arthroscopic subacromial decompression (ASD) was developed to be able to go in and shave away the Acromion and give the tendon’s more space.
Initial reports indicated good success rate. A 1987 study from the Department of Orthopaedic Surgery, University of California at Los Angeles wrote: “Eighty-eight percent of the cases were rated “satisfactory” (excellent or good), and 12% were rated “unsatisfactory” (fair or poor),” when performed by experienced physicians.(2)
As the years went on however doctors began to doubt the surgery.
In 2013, Dr. Robert Zaray Tashjian published research the Clinical journal of sports medicine suggesting that surgical interventions for subacromial impingement syndrome do not reveal one surgical technique to be better than another, nor do they show that surgery is superior in any way to conservative interventions.(3)
Further, data in the medical journal Arthroscopy showed when young athletes have arthroscopic stabilization surgery, it must be emphasized to the patients and their families that the recurrence rate (the need for another surgery) following arthroscopic procedures is higher in young people than in the adult population.(4)
Research like this suggests that shoulder impingement surgery may not be the fastest way back to sports or activity and the prospect of more surgery needs to be considered.
A patient with problems of the rotator cuff or shoulder impingement may think that surgery will be a quick fix. However, surgery is an invasive procedure that often requires lengthy recovery and physical therapy even if it is successful. Further, even “successful” surgery may not relieve the pain, and shoulder weakness can remain. Complications can also include nerve damage and increased weakness.
One study from doctors at New York University and published in The Journal of the American Academy of Orthopaedic Surgeons noted that “most patients experience pain relief and functional improvement following arthroscopic rotator cuff repair, but some continue to experience symptoms post-operatively. Patients with so-called failed rotator cuff syndrome, that is, with continued pain, weakness, and limited active range of motion following arthroscopic rotator cuff repair, present a diagnostic and therapeutic challenge.”(5)
Subacromial decompression no better than placebo surgery
The University of Helsinki reports on a landmark study from their researchers published July 19, 2018 in the British Medical Journal, Finnish researchers show that one of the most common surgical procedures in the Western world is probably unnecessary. Keyhole surgeries of the shoulder are useless for patients with “shoulder impingement”, the most common diagnosis in patients with shoulder pain.
“These results show that this type of surgery is not an effective form of treatment for this most common shoulder complaint. With results as crystal clear as this, we expect that this will lead to major changes in contemporary treatment practices,” said the study’s principal investigators chief surgeon Mika Paavola and professor Teppo Järvinen from the Helsinki University Hospital and University of Helsinki.
“By ceasing the procedures which have proven ineffective, we would avoid performing hundreds of thousands useless surgeries every year in the world”, Järvinen points out. You can read the press release here
Research: Subacromial decompression – little if any benefit – but the surgery is still recommended
In March 2019, surgeons at McMaster University in Canada published their review which suggested evidence that surgical intervention has little, if any, benefit for impingement pathology in the middle-aged patient. In this study published in the Journal of the Canadian Medical Association (CMAJ Open (6)) the researchers stated emphatically:
- “Surgical intervention for subacromial impingement syndrome may have little if any benefit with respect to pain and functional outcomes in the short and long term in comparison with nonoperative treatments such as exercise and physiotherapy alone. Our findings are strengthened by the inclusion of randomized controlled trials, a sufficiently large pooled sample of patients, confidence intervals that excluded our threshold of a minimal clinical importance and low heterogeneity across studies.” In other words, the researchers were pretty sure the surgery did not work.
At Monash University in Australia, doctors published a 2019 study (7) which made these suggestions:
- The data in this (study) do not support the use of subacromial decompression in the treatment of rotator cuff disease manifest as painful shoulder impingement. High-certainty evidence shows that subacromial decompression does not provide clinically important benefits over placebo in pain, function or health-related quality of life. Including results from open-label trials (with high risk of bias) did not change the estimates considerably. Due to imprecision, we downgraded the certainty of the evidence to moderate for global assessment of treatment success; there was probably no clinically important benefit in this outcome either compared with placebo, exercises or non-operative treatment.”
In August 2021, the question as to whether to have this surgery or not was the subject of a paper on developing patient decision aids to help the patient decide if this surgery is warranted for them.(8)
Shoulder Impingement Surgery Alternatives
Although “impingement” refers specifically to pressure on the tendons and bursa in the shoulder, it is a generalized term often used to refer to shoulder pain of unknown origin. Other terms used to describe pain that cannot be pinpointed are tendinitis, tendinosis, and bursitis. When a patient comes into our office we will perform a detailed physical examination of the shoulder looking for pain generators. Spots on the shoulder that elicit a pain response when pressed. Typically these are the spots of damage.
By isolating the areas that are damaged and injecting these spots with stem cells we can be confident that healing can occur.
The connection between Subacromial impingement of the rotator cuff and the development of rotator cuff tendinopathy is clear. In many patients we see the impingement and the tendinopathy are only parts and contributing factors to shoulder pain.
This is pointed out in our research which appears in the peer-reviewed journal Cogent Medicine. The study can be found here in its entirety: Treatment of shoulder osteoarthritis and rotator cuff tears with bone marrow concentrate and whole bone marrow injections with a June 20, 2019 publication date.
Here we were able to demonstrate that:
- Patients with rotator cuff tendinopathy and degenerative shoulder disease would benefit from either one and two stem cell treatments. Patients reported significant improvements in resting pain, active pain, and functionality score when compared to baseline.
- These groups also experienced a 42.25% and 50.17% overall improvement respectively.
- The group that received two treatments experienced statistically significant improvements in active pain when compared to the group that received one injection.
- There were no significant outcome differences between rotator cuff tear and osteoarthritis patients.
Conclusions: Our study demonstrated that patients diagnosed with shoulder osteoarthritis or rotator cuff tears experienced symptomatic improvements in pain and functionality when injected with bone marrow concentrate (BMC) or whole bone marrow (WBM). Further randomized control studies are needed to validate these findings.
Do you have questions? Ask Dr. Darrow
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Stem cell and PRP injections for musculoskeletal conditions are not FDA approved. We do not treat disease. We do not offer IV treatments. There are no guarantees that this treatment will help you. Prior to our treatment, seek advice from your medical physician. Neither Dr. Darrow, nor any associate, offer medical advice from this transmission. This information is offered for educational purposes only. The transmission of this information does not create a physician-patient relationship between you and Dr. Darrow or any associate. We do not guarantee the accuracy, completeness, usefulness or adequacy of any resource, information, product, or process available from this transmission. We cannot be responsible for the receipt of your email since spam filters and servers often block their receipt. If you have a medical issue, please call our office. If you have a medical emergency, please call 911.
1 De Martino I, Rodeo SA. The swimmer’s shoulder: multi-directional instability. Current reviews in musculoskeletal medicine. 2018 Jun;11(2):167-71.
2 Ellman H. Arthroscopic subacromial decompression: analysis of one-to three-year results. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 1987 Jan 1;3(3):173-81.
3 Tashjian RZ. Is there evidence in favor of surgical interventions for the subacromial impingement syndrome? Clin J Sport Med. 2013 Sep;23(5):406-7. doi: 10.1097/01.jsm.0000433152.74183.53.
4 Castagna A, Delle Rose G, Borroni M, Cillis BD, Conti M, Garofalo R, Ferguson D, Portinaro N. Arthroscopic stabilization of the shoulder in adolescent athletes participating in overhead or contact sports. Arthroscopy. 2012 Mar;28(3):309-15. doi: 10.1016/j.arthro.2011.08.302. Epub 2011 Nov 30.
5 Strauss EJ, McCormack RA, Onyekwelu I, Rokito AS. Management of failed arthroscopic rotator cuff repair. J Am Acad Orthop Surg. 2012 May;20(5):301-9.
6 Khan M, Alolabi B, Horner N, Bedi A, Ayeni OR, Bhandari M. Surgery for shoulder impingement: a systematic review and meta-analysis of controlled clinical trials. CMAJ open. 2019 Jan;7(1):E149.
7 Karjalainen TV, Jain NB, Page CM, Lähdeoja TA, Johnston RV, Salamh P, Kavaja L, Ardern CL, Agarwal A, Vandvik PO, Buchbinder R. Subacromial decompression surgery for rotator cuff disease. Cochrane Database of Systematic Reviews. 2019(1).
8 Zadro J, Jones C, Harris I, Buchbinder R, O’Connor DA, McCaffery K, Thompson RE, Karunaratne S, Teng MJ, Maher C, Hoffmann T. Development of a patient decision aid on subacromial decompression surgery and rotator cuff repair surgery: an international mixed-methods study. BMJ Open. 2021 Aug 30;11(8):e054032. doi: 10.1136/bmjopen-2021-054032. PMID: 34462283.