Shoulder procedures

A systematic review evaluating surgery for shoulder impingement found no clinically significant benefit to surgical intervention over non operative treatment in middle aged patients (1). 

A multi-centre randomised trial found that subacromial decompression did not differ from arthroscopy alone (2). Even though both surgeries provided more symptom improvement than no treatment, the difference was not clinically significant.

Another systematic review assessed the role of subacromial decompression surgery in patients with long-term subacromial pain syndrome (3). The findings had no important benefit when compared to both placebo surgery and exercise therapy. 

Lastly, the Cochrane Review for surgery for rotator cuff disease also concluded there was no benefit to people at one year follow up (4).  There was no improvement in pain, function or quality of life when compared with placebo surgery.

There is substantial evidence against the isolated use of arthroscopic subacromial decompression in patients with subacromial pain syndrome. Therefore, we do not routinely fund claims for this procedure. We will continue to fund subacromial decompression in the context of ACJ pathology, calcific deposit and rotator cuff tears, when initial injection treatment and physiotherapy has not been effective.

The recent GIRFT report (2020) stated that they are working to reduce the number of unnecessary shoulder surgeries especially in patients with subacromial pain without 6 weeks of physiotherapy. 

The evidence supporting Platelet-rich plasma (PRP) injections use has been inconclusive. The Cochrane review found that research evidence is insufficient to support its use in treating musculoskeletal soft tissue injuries (6).

A systematic review also concluded that PRP may not be beneficial for non-operative treatment of chronic rotator cuff disease (7). Also, the review suggested that PRP use did not result in improved outcomes in function, pain or range of movement.

On the other hand, another systematic review evaluating the role of PRP in improving pain and function in rotator cuff tears did suggest that it may positively affect clinical outcomes (8). However, due to limited data and poor methodology they could not make firm conclusions over its usage.

Lastly, a review of multiple studies regarding the use of PRP in the management of shoulder pathologies found minimal benefits for shoulder pain, function and healing (9). Overall, the evidence remains unclear with more randomised controlled trials needed to further evaluate its use.

As per the current evidence base, Vitality does not routinely fund claims for platelet-rich plasma injections in relation to shoulder conditions.

According to NICE guidance, intra-articular corticosteroid injections should be only considered as an addition to core treatments for relief of moderate to severe pain in patients with osteoarthritis (10). Also, NICE guidelines do not recommend to undertake Hyaluronic acid injections.

In the management of rotator cuff tendinopathy or impingement, an injection into the subacromial space can be considered to achieve pain relief but repeated injections may cause tendon damage (12).

The use of steroid injections depends upon the clinical indication that they are being used.

We’ll fund one steroid injection per shoulder as a sole procedure per year, but only for GHJ or ACJ injections for degenerative disease, and not on an ongoing basis for regular pain management. If there is significant improvement, we may fund one further injection within a 12 month period.

For rotator cuff pathology an initial injection is often used alongside physiotherapy and may be repeated in order to facilitate their ongoing therapy. We will fund two injections in the management of rotator cuff pathology, but only where this is taking place alongside physiotherapy.

Similarly for adhesive capsulitis we will fund an initial injection in order to facilitate physiotherapy and if this is not effective we will fund a one final injection of saline hydrodistension if appropriate (11).

We don’t fund hyaluronic acid injections or injections of other substances, in line with NICE guidance. We also won’t fund an injection when it’s carried out in conjunction with another therapeutic procedure, where we would expect this to be part and parcel of the treatment offered.

Before considering the injection, for management of rotator cuff tendinopathy or impingement the following measures should be tried (12):
• Education, rest, NSAIDs, simple analgesia
• Appropriate structured physiotherapy with goal setting for 6 weeks.

Arthroscopic Subacromial Decompression
1. Khan, M., Alolabi, B., Horner, N., Bedi, A., Ayeni, O. R., & Bhandari, M. (2019). Surgery for shoulder impingement: a systematic review and meta-analysis of controlled clinical trials. CMAJ open, 7(1), E149.
2. Beard, D. J., Rees, J. L., Cook, J. A., Rombach, I., Cooper, C., Merritt, N., ... & Moser, J. (2018). Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW): a multicentre, pragmatic, parallel group, placebo-controlled, three-group, randomised surgical trial. The Lancet, 391(10118), 329-338.
3. Lähdeoja, T., Karjalainen, T., Jokihaara, J., Salamh, P., Kavaja, L., Agarwal, A.,& Ardern, C. L. (2020). Subacromial decompression surgery for adults with shoulder pain: a systematic review with meta-analysis. British journal of sports medicine, 54(11), 665-673.
4. Karjalainen, T. V., Jain, N. B., Page, C. M., Lähdeoja, T. A., Johnston, R. V., Salamh, P., ... & Buchbinder, R. (2019). Subacromial decompression surgery for rotator cuff disease. Cochrane Database of Systematic Reviews, (1).
5. Getting it Right First Time (2020) Getting it Right in Orthopaedics. Reflecting on success and reinforcing improvement. A follow up on the GIRFT national specialty report on orthopaedics. Retrieved from: https://gettingitrightfirsttime.co.uk/wp-content/uploads/2020/02/GIRFT-orthopaedics-follow-up-report-February-2020.pdf

Platelet-Rich Plasma Injection
6. Moraes, V. Y., Lenza, M., Tamaoki, M. J., Faloppa, F., & Belloti, J. C. (2014). Platelet‐rich therapies for musculoskeletal soft tissue injuries. Cochrane Database of Systematic Reviews, (4).
7. Hurley, E. T., Hannon, C. P., Pauzenberger, L., Fat, D. L., Moran, C. J., & Mullett, H. (2019). Nonoperative treatment of rotator cuff disease with platelet-rich plasma: a systematic review of randomized controlled trials. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 35(5), 1584-1591.
8. Chen, X., Jones, I. A., Togashi, R., Park, C., & Vangsness Jr, C. T. (2020). Use of platelet-rich plasma for the improvement of pain and function in rotator cuff tears: a systematic review and meta-analysis with bias assessment. The American journal of sports medicine, 48(8), 2028-2041.
9. Schneider, A., Burr, R., Garbis, N., & Salazar, D. (2018). Platelet-rich plasma and the shoulder: clinical indications and outcomes. Current reviews in musculoskeletal medicine, 11(4), 593-597.

Corticosteroid Injection
10. National Institute for Health and Care Excellence (2014). Osteoarthritis: care and management. NICE Clinical guideline. Retrieved from: nice.org.uk/guidance/cg177
11. British Elbow & Shoulder Society (2015). BESS/BOA Patient Care Pathways: Frozen Shoulder. Shoulder & Elbow. Vol 7(4) 299-307.
12. British Orthopaedic Association (2014) Commissioning Guide: Subacromial Shoulder Pain. Retrieved from: https://www.boa.ac.uk/uploads/assets/uploaded/f4bfe04a-0450-4eab-b9acad9dbb5d8c86.pdf