Subacromial Decompression

Understanding the Condition

The rotator cuff is a group of muscles and tendons that stabilize your shoulder joint and allow you to lift and rotate your arm. Over time, wear and tear can lead to rotator cuff disease, a condition that often results in shoulder pain, particularly during overhead movements or when lying on the affected side. One contributing factor to this pain may be impingement, where tendons are compressed by surrounding bone structures, especially the acromion.

Subacromial decompression surgery was developed to alleviate this pressure. The procedure involves removing inflamed tissue (bursa) and trimming the underside of the acromion bone to create more space for the rotator cuff tendons, thereby reducing mechanical irritation.

The Surgery in Focus

Subacromial decompression is typically performed arthroscopically, using small incisions and a camera. After surgery, patients may wear a sling and begin physical therapy, which continues for several months. Risks of surgery include infection, nerve injury, stiffness (frozen shoulder), and extremely rare serious complications such as pulmonary embolism or cardiac events.

Despite being a common procedure—with tens of thousands performed annually in the U.S. and U.K.—recent high-quality research has challenged the assumed benefits of this surgery.

What the Research Shows

Two large, well-conducted placebo-controlled trials (where participants underwent sham surgery or no treatment) have shown little to no benefit from subacromial decompression when compared to non-surgical treatments like exercise therapy.

Pain Relief

One year after surgery, people reported only a 0.26-point difference in pain (on a 0–10 scale) compared to those who had placebo surgery—a result too small to be meaningful to most patients. In fact, the average pain score was about 2.6 with surgery and 2.9 with placebo, which falls within normal variability.

Shoulder Function

Function scores also showed negligible difference. On a 0–100 scale (where higher is better), patients improved by about 2.8 points more after surgery compared to placebo—well below the 8.3-point threshold considered clinically important.

Overall Success and Satisfaction

About 66% of patients considered their treatment successful with placebo surgery. That number increased only marginally—to 71%—with subacromial decompression. Statistically, this difference was not significant.

Quality of Life

Health-related quality of life scores were virtually unchanged, with a 0.03-point difference on standardized measures like the EQ-5D and 15D scales (scales where a 0.07-point change is considered meaningful).

Comparing Surgery to Exercise Therapy

In trials comparing surgery to physiotherapy alone, results were similarly modest:

• Pain was reduced by only 1 point on a 10-point scale—again falling short of the 1.5-point threshold for meaningful relief.
• Functional improvements were minimal and inconsistent across studies.
• Quality of life and treatment success were not significantly different.

In other words, exercise therapy produced similar outcomes to surgery, without the risks or recovery time.

Risks and Harms

Minor Complications

Across studies, adverse events such as shoulder stiffness or transient discomfort occurred in only 3% of patients. The rates were similar between surgery and placebo groups, suggesting no substantial increase in minor risks with surgery.

Serious Complications

While rare, serious complications—like infection, nerve damage, or pulmonary embolism—occurred in 5 to 6 per 1,000 patients based on registry data. These events were not reported in the randomized trials but were observed in large observational studies.

The Bottom Line

Based on the highest-quality evidence to date, subacromial decompression surgery offers no meaningful advantage over placebo surgery or structured exercise therapy in treating shoulder impingement without full-thickness rotator cuff tears.

What Should You Do?

If you’re experiencing shoulder pain:

• Start with non-surgical treatments like physiotherapy, activity modification, and anti-inflammatory medications.
• Surgery should not be the first option, especially given its limited benefits and potential risks.
• Consider all options and discuss them thoroughly with your orthopedic specialist.

Key Takeaways

• Subacromial decompression does not significantly reduce pain or improve function more than placebo or exercise.
• Risks from surgery are low but not zero.
• Exercise therapy is often just as effective, without the risks or downtime.

 

Do you have more questions?

Q. What is subacromial decompression surgery?
A. Subacromial decompression is a surgical procedure that involves removing inflamed or damaged tissue and bone spurs from the space between the top of the shoulder and the rotator cuff to relieve pain and improve shoulder function.

Q. What symptoms may indicate the need for subacromial decompression?
A. Symptoms include persistent shoulder pain, especially with overhead movements, pain at night, limited range of motion, and weakness in the shoulder that does not improve with non-surgical treatment.

Q. What causes subacromial impingement?
A. Subacromial impingement can be caused by repetitive overhead activity, bone spurs, inflammation of the rotator cuff tendons or bursa, and age-related degenerative changes.

Q. What are non-surgical treatments for subacromial impingement?
A. Non-surgical treatments include physical therapy, anti-inflammatory medications, corticosteroid injections, and activity modification.

Q. When is subacromial decompression surgery recommended?
A. Surgery is recommended when symptoms persist despite extensive non-surgical treatment, typically after several months of conservative care.

Q. What does the subacromial decompression procedure involve?
A. The procedure is usually done arthroscopically and involves removing the inflamed bursa, shaving part of the acromion bone, and sometimes removing bone spurs to create more space for the rotator cuff tendons.

Q. Is subacromial decompression performed as an open or arthroscopic surgery?
A. It is most commonly performed arthroscopically through small incisions using a camera and specialized instruments.

Q. How long does subacromial decompression surgery take?
A. The surgery typically takes less than an hour to complete.

Q. What type of anesthesia is used for subacromial decompression?
A. The procedure is usually performed under general anesthesia or a regional nerve block.

Q. What is the recovery time after subacromial decompression?
A. Recovery time can vary, but most patients resume normal activities within a few weeks, with full recovery taking several months depending on the individual and any associated procedures.

Q. Will I need physical therapy after surgery?
A. Yes, physical therapy is an essential part of recovery to restore shoulder strength, flexibility, and range of motion.

Q. What are the risks associated with subacromial decompression?
A. Risks include infection, bleeding, stiffness, nerve injury, and failure to relieve symptoms.

Q. How successful is subacromial decompression in relieving symptoms?
A. Most patients experience significant relief of pain and improved shoulder function, especially when the surgery is performed for impingement without significant rotator cuff damage.

Q. Can subacromial decompression be combined with other procedures?
A. Yes, it is often combined with procedures like rotator cuff repair or distal clavicle excision when indicated.