Do you have shoulder pain?
If you do, you’re not alone. Shoulder pain ranks just shy of lower back pain when it comes to causes of disability & pain. That makes it a fairly common reason that patients may schedule an appointment with a doctor or specialist, like an orthopedic surgeon. While there may be many causes & underlying factors that contribute to shoulder pain, the vast majority of cases involve some sort of injury or disorder of the rotator cuff.
Patients experiencing shoulder pain may have difficulty lifting their arm overhead, reaching out to the side, or carrying things with that arm. Some people notice stiffness or decreased motion as a result of their shoulder pain.
That being said, finding the right treatment option can be a challenge. Hopefully, this article helps shed some light, and help help you make the best decision about how to manage and treat shoulder or rotator cuff pain.
What About Treatment? Therapy vs. Injections & Surgery
Rotator cuff disorders result in 70% of the total yearly clinic visits for shoulder pain [1]. Now, even though roughly 7 out of 10 patients with shoulder pain have some kind of rotator cuff injury or disease, there’s still a lot of confusion about which treatment option is best. And in reality, the “best” treatment for you may be different than someone else based on your own, unique, biopsychosocial factors. But let’s take look at what the research shows about which treatments tend to be effective for treating shoulder pain and rotator cuff disorders.
Treatment options range from injections, surgery, or physical/occupational therapy. And the results for each treatment option in the literature or research tend to be mixed and unclear. For example, some studies show better outcomes for operative interventions (surgery) [1] while others show little to no difference between operative and non- operative treatment [2]. And yet, more studies suggest that, for long-term outcomes, conservative management (like physical/occupational therapy) for small rotator cuff tears is favorable to surgery [3].
With all of these options, selecting the best course of care poses a challenge. The general guidelines from the research suggest opting for the most effective intervention that carries the lowest risk of adverse reactions. Basically, we want to start with the least invasive form of treatment first, then move to more invasive options if needed.
How does surgery vs. physical/occupational therapy treatment affect pain outcomes?
In one systematic review, at a twelve-month follow-up, there was a statistically significant differences in the Visual Analogue Scale (VAS) scores in favor operative groups compared to non- operative groups [2]. This means, that, in this study, patients that had surgery experienced less pain after 1 year than patients who completed a conservative treatment plan with therapy.
However, there’s also evidence to suggest that differences in both Constant and VAS scores are small and do not meet the minimal difference considered clinically significant [1]. These studies show that, while there is a statistically significant difference between surgery and conservative treatment, these differences aren’t clinically significant. Simply put: while there are some detectable changes between surgery & therapy for treating rotator cuff and shoulder pain, these differences are not large enough to change clinical practice.
Think of it this way: a statistically significant change for the numerical rating scale of pain (where you rate your pain on a scale of 1 to 10) is about 1.39 [4]. So, to be “significant” for research purposes, patients could decrease their pain levels from a 10/10 to an 8/10; and that would be considered “significant”. But let me ask you, if you started at a 10/10 and were only able to lower it down to 8/10 through surgery, would that be worth it to you? Sometimes, the answer may be yes. Sometimes, it may not be worthwhile to take the risk of complications that come with surgery, only to reduce pain level by 2 points.
In the end, when it comes to pain as the primary outcome measure, more studies with longer follow-ups are needed to determine whether clinically significant differences between treatments becomes evident over time. This basically means that there’s still a lot of blurriness in this area of the research available to us.
What about the risk of complications and long-term outcomes for pain and function?
One meta-analysis comparing surgery vs. therapy for rotator cuff four that: “There is limited evidence that surgery is not more effective in treating rotator cuff tear than conservative treatment alone. There was no clinically significant difference between surgery and active physiotherapy (PT/OT) in 1-year follow-up in improving Constant score or reducing pain caused by rotator cuff tear. As physiotherapy is less prone to complications and less expensive than surgery, a conservative approach is advocated as the initial treatment modality to rotator cuff tears.” [3]
That study concluded that, since surgery and therapy both yield similar outcomes when it comes to pain and function, then it doesn’t make sense to jump straight to surgery. The authors of this study suggest starting with conservative treatment options like physical and occupational therapy, aquatic therapy, and the like before moving on to more invasive —and more expensive— treatment options like surgery.
Summary
There’s never a one-size-fits-all or “best” treatment option for dealing with shoulder and rotator cuff pain —or any pain, really. Treatment options and approaches should be based on your goals, your unique situation and context, and any other social or environmental factors that may affect your situation. The research suggests starting with less invasive —and less expensive— treatment options, and reserving surgery or more invasive options for later in the treatment plan. You should speak with your doctor or surgeon about your specific situation, and whether it makes sense to start with a conservative treatment approach for your shoulder pain.
And, if you have any questions about the type of options available, and how physical and occupational therapy can empower you to chart a holistic path to healing, then reach out and talk to a member of our care team. We’d love to chat with you about what you have going on, and how ProActive Rehabilitation & Wellness can help.
References
[1] Piper CC, Hughes AJ, Ma Y, Wang H, Neviaser AS. Operative versus nonoperative treatment for the management of full-thickness rotator cuff tears: a systematic review and meta-analysis. J Shoulder Elbow Surg. 2018 Mar;27(3):572-576. doi: 10.1016/j.jse.2017.09.032. Epub 2017 Nov 21. PMID: 29169957.
[2] Longo, U.G., Risi Ambrogioni, L., Candela, V. et al. Conservative versus surgical management for patients with rotator cuff tears: a systematic review and META- analysis.BMC Musculoskelet Disord 22, 50 (2021). https://doi.org/10.1186/s12891-020-03872-4
[3] Ryösä A, Laimi K, Äärimaa V, Lehtimäki K, Kukkonen J, Saltychev M. Surgery or conservative treatment for rotator cuff tear: a meta-analysis. Disabil Rehabil. 2017 Jul;39(14):1357-1363. doi: 10.1080/09638288.2016.1198431. Epub 2016 Jul 6. PMID: 27385156.
[4] Kendrick DB, Strout TD. The minimum clinically significant difference in patient-assigned numeric scores for pain. Am J Emerg Med. 2005 Nov;23(7):828-32. doi: 10.1016/j.ajem.2005.07.009. PMID: 16291435.
