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Clinical RheumatologyJournal of the International League ofAssociations for Rheumatology ISSN 0770-3198 Clin RheumatolDOI 10.1007/s10067-014-2563-9

Efficacy of surgery for rotator cufftendinopathy: a systematic review

Panagiota Toliopoulos, FrançoisDesmeules, Jennifer Boudreault, Jean-Sébastien Roy, Pierre Frémont, JoyC. MacDermid, et al.

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REVIEWARTICLE

Efficacy of surgery for rotator cuff tendinopathy:a systematic review

Panagiota Toliopoulos & François Desmeules & Jennifer Boudreault &Jean-Sébastien Roy & Pierre Frémont & Joy C. MacDermid & Clermont E. Dionne

Received: 7 January 2014 /Revised: 23 February 2014 /Accepted: 26 February 2014# Clinical Rheumatology 2014

Abstract The objective of this study is to review random-ized controlled trials evaluating the efficacy of surgery forthe treatment of rotator cuff (RC) tendinopathy. Studies upto August 2013 were located in the PubMed, Embase,CINAHL, and PEDro databases using relevant keywords.Studies were included if: (1) participants had rotator cufftendinopathy, (2) the trials were conducted on an adultpopulation (≥18 years old), (3) at least one of the interven-tions studied was a surgical procedure, (4) study design wasa randomized controlled trial (RCT), and (5) the article waswritten in English or French. Characteristics of the includedstudies were extracted using a standardized form. Twoindependent raters reviewed the methodological quality ofthe studies using the Risk of Bias Assessment tool devel-oped by the Cochrane Collaboration Group. Differenceswere resolved by consensus. Fifteen trials met our inclusioncriteria. After consensus, the mean methodological qualityfor all studies was 58.9±10.8 %. In three out of four RCTsof moderate or low methodological quality, no significant

difference in treatment effectiveness was observed betweenopen or arthroscopic acromioplasty compared to exercisesin the treatment of RC tendinopathy. Based on two studiesof low or moderate methodological quality, no difference intreatment effectiveness was observed between arthroscopicand open acromioplasty. Two other RCTs of low to moder-ate quality, however, found that arthroscopic acromioplastyyielded better results in the short-term for shoulder range ofmotion in flexion but that both procedures were comparablein the long-term. One additional study favored openacromioplasty over arthroscopic acromioplasty for thetreatment of RC tendinopathy. Based on low- tomoderate-quality evidence, acromioplasty, be it open orarthroscopic, is no more effective than exercises for thetreatment of RC tendinopathy. Low-grade evidence alsosuggests that arthroscopic acromioplasty may yield betterresults in the short-term for shoulder range of motion inflexion compared to open acromioplasty, but long-termresults are comparable between the two types of surgery.

P. Toliopoulos : F. Desmeules (*) : J. BoudreaultOrthopaedic clinical research unit, Maisonneuve-Rosemont HospitalResearch Center, University of Montreal Affiliated Research Center,Montreal, QC, Canadae-mail: f.desmeules@umontreal.ca

F. DesmeulesSchool of Rehabilitation, Faculty of Medicine, University ofMontreal, Montreal, QC, Canada

J.<S. Roy : P. FrémontDepartment of Rehabilitation, Faculty ofMedicine, Laval University,Quebec City, QC, Canada

J.<S. RoyCentre for Interdisciplinary Research in Rehabilitation and SocialIntegration, Quebec City, QC, Canada

P. Frémont : C. E. DionneResearch Centre of the Laval University Hospital (CHU), Quebec,QC, Canada

J. C. MacDermidSchool of Rehabilitation Science, McMaster University, IAHS,Hamilton, ON, Canada

C. E. DionnePopulation Health Research Unit (URESP), Research Centre of theLaval University Hospital (CHU), Quebec, QC, Canada

Clin RheumatolDOI 10.1007/s10067-014-2563-9

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More high-quality RCTs are required in order to providecomprehensive treatment guidelines to healthcareproviders.

Keywords Acromioplasty . Rotator cuff tendinopathy .

Shoulder . Surgery . Systematic review

Introduction

Rotator cuff (RC) tendinopathy, also referred to as “shoulderimpingement syndrome (SIS)”, is the most common patholo-gy encountered in the shoulder and encompasses a variety ofconditions including subacromial bursitis, partial rotator cufftears, and bicipital tendinosis [1, 2]. RC tendinopathy causespain and limits patients’ movements, thereby preventing ac-tivities of daily living and often resulting in time away fromwork. The prevalence of shoulder conditions increases withage, with estimated point prevalence being as high as 26 %and lifetime prevalence as high as 67 % [3].

RC tendinopathy is believed to originate from extrinsiccauses, intrinsic causes, or a combination of both. Extrinsiccauses, which result in compression of the rotator cuff tendonsand surrounding tissues, include anatomical variants of theacromion, a thickened coracoacromial ligament, subacromialbursitis, or postural abnormalities [4, 5]. Intrinsic causes areassociated with degeneration of the rotator cuff tendons andinclude age-related degeneration that may vary in severityaccording to genetic predisposition, a deficient vascular sup-ply, or a history of trauma [5].

The diagnosis of RC tendinopathy is usually based on thepatient’s history and on clinical tests such as the painful arc orRC impingement tests [6]. The first line of treatment for RCtendinopathy is conservative management, which may in-volve any combination of the following: anti-inflammatorymedications, corticosteroid injections, or exercises. Surgery isindicated in patients in whom conservative treatment hasfailed and multiple surgical techniques exist [6].Acromioplasty, also referred to as “subacromial decompres-sion”, is a surgical technique where the anterior edge and theundersurface of the anterior part of the acromion are removed.It was pioneered by Neer in 1972, and it is routinely used inthe treatment of RC tendinopathy today [4]. Alternatively,bursectomy can be performed without acromioplasty and isthe preferred technique of some surgeons because it does notalter the coracoacromial arch [7]. Other surgical proceduresfor RC tendinopathy exist, but they are relatively new and notwidely used: for example, radiofrequency (RF)-basedmicrotenotomy is a procedure during which a RF-based probeis used to perform microdebridement in the supraspinatustendon [8]. Over the past two decades, surgical techniqueshave evolved from open procedures to arthroscopic, whichavoid wide dissection and subsequent large scarring. Some

authors claim that arthroscopic procedures allow for quickeroperating times, better post-operative mobility, and less com-plications [9], whereas others believe that the two proceduresare equivalent in terms of efficacy and quality of life [10].

It is important to note that an evidence-based consensusis not currently available to guide the decision-makingprocess for the surgical treatment of RC tendinopathy.Furthermore, systematic reviews evaluating the efficacyof surgery are scarce and the latest available review waspublished in 2009; the review in question is a Cochranereview by Coghlan et al. which assessed whether surgerywas an effective and safe approach in the treatment of RCtendinopathy [11]. The authors found that there was insuf-ficient evidence to reach any definitive conclusions on theefficacy of surgery. The review synthesized the researchthat had been completed until 2008, and consequently, thereare new studies that have been published in the last 5 yearsthat it did not take into account. Therefore, the purpose ofthe present systematic review is to provide an up-to-datesynthesis of randomized control trials (RCTs) on the effi-cacy of surgery to reduce pain and improve function inadults with RC tendinopathy.

Methods

Literature search and study identification

We searched four bibliographical databases PubMed, Embase,CINAHL, and the Physiotherapy Evidence Database (PEDro)using a combination of keywords and MESH terms (Appen-dix). Searches were performed from date of inception toAugust 2013. The electronic search was supplemented byhand searching the reference sections of all trials and previoussystematic reviews conducted on this topic.

Study selection

Articles were deemed eligible to be included in our sys-tematic review after two authors reviewed the title, ab-stract, and full article (if needed) and determined whetherthey met the following inclusion criteria: (1) participantswere described to have RC tendinopathy or shoulder im-pingement syndrome, subacromial bursitis, partial rotatorcuff tear, or bicipital tendinosis, (2) the trials were con-ducted on an adult population (≥18 years old), (3) at leastone of the interventions studied was a surgical procedureand was compared to any other treatment modality, (4)study design was a RCT, and (5) the article was written ineither English or French. Trials were excluded if theirstudy population consisted of patients with full thicknessrotator cuff tears, with calcifying tendonitis, or with othershoulder pathologies.

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Data extraction

Characteristics of the included studies were extracted using astandardized form. Data extracted included participant char-acteristics (age and gender), diagnostic and eligibility criteria,intervention types studied, co-interventions, outcome mea-sures, follow-up time points, complications, and main results.If two surgical techniques were compared in a study, the timeit took to complete each surgery as well as data pertaining tothe economic impact of each treatment modality were extract-ed when available.

Methodological appraisal and analyses

We used the Cochrane risk of bias tool to assess the method-ological quality of the included studies [12]. This tool allowsfor the evaluation of the following eight methodological do-mains: sequence generation, allocation concealment, blindingof participants, blinding of providers, blinding of assessors,incomplete outcome data, selective outcome data reporting,and other sources of bias. Two independent reviewers attrib-uted a score to each methodological domain on a scale of 0 to2, where 0 meant that a high risk of bias was present, 1 meantthat the risk of bias could not be determined, and 2 meant thata low risk of bias was present. Disagreements between the tworeviewers were resolved by consensus. Cohen’s kappa wasused to calculate pre-consensus inter-rater agreement. A totalscore out of 16 points was calculated for each RCT by doingthe sum of the scores of the eight methodological domains,and an intraclass correlation coefficient (ICC) was calculatedto evaluate inter-rater reliability. Studies were not excluded onthe basis of their methodological quality. Studies comparingsimilar interventions with analogous outcome measures wereidentified and pooled through a meta-analysis. Heterogeneitywas assessed using the I2 measure. An I2<60 % was consid-ered to be acceptable for pooling results as recommended bythe Cochrane Collaboration [12].

Results

Description and findings of included studies

The literature search identified 15 publications that comparedthe efficacy of different types of surgery for the treatment ofRC tendinopathy that met our eligibility criteria (Fig. 1). Inorder to identify these 15 publications, the full text of 25articles was read and 10 articles were excluded. Seven studieswere excluded because the participants were not specificallydiagnosed with RC tendinopathy: in six studies, the partici-pants had full thickness RC tears [13–18], and in one addi-tional study, patients had chronic calcifying tendinopathy[19]. Two other studies were excluded because they compared

different suture materials or holmium laser versus electrocau-tery for soft tissue resection [20, 21], and finally, one studywas excluded because it had a retrospective design [22]. Thestudies of Brox et al. [23, 24], Haahr et al. ([25]), Norlin [28],and Lindh and Norlin [27] each reported short- and long-termresults from a same cohort of participants in two publications,and therefore, these results were analyzed together [23–28](Table 1).

All the studies included in this review were designed tocompare two different treatment modalities for RCtendinopathy with the restriction that at least one of the treat-ments had to be surgical. Three studies compared a rehabili-tation program with either arthroscopic subacromial decom-pression or open anterior acromioplasty [25, 26, 29, 30], andone study compared arthroscopic subacromial decompressionor exercise to a placebo [23, 24]. Finally, eight studies com-pared subacromial bursectomy or debridement of thesubacromial bursa followed by acromioplasty oracromioplasty alone or RF-based microtenotomy and eithermade the comparison between two distinct procedures orbetween the same procedures done openly or by arthroscopy[31–33, 27, 28, 34–36, 8]. We planned to pool results frommultiple studies to perform a meta-analysis. However, wewere unable to do so because only two studies compared thesame procedures (open subacromial decompression and ar-throscopic subacromial decompression) while using similaroutcome measures (University of California, Los Angeles(UCLA) score at 12 months) [32, 36]. These two studiesdemonstrated significant heterogeneity (τ2=7.32, χ2=2.75,df=1 (p=0.10), and I2=64 %), which made them inappropri-ate to combine. Consequently, since we were unable to per-form a meta-analysis, we performed a narrative synthesissummarizing the findings in studies meeting our inclusioncriteria.

Risk of bias of included studies

The methodological quality of the included studies is de-scribed in Table 1. Mean methodological score was 58.9±10.8% (range, 43.8–81.3 %) suggesting a low to moderatemethodological quality of the studies. Seven trials had amethodological score exceeding 50 %. The ICC for overallconcordance in methodological score between reviewers was0.81 (95 % CI, 0.38 to 0.94). Pre-consensus inter-rater agree-ment ranged from poor to perfect agreement (κ=0.31 to 1.00)for the eight methodological domains of the Cochrane Risk ofBias tool with four categories having a κ=1.00 (sequencegeneration, blinding of personnel, outcome assessors, andselective outcome reporting) and one category (other bias)having a κ=0.31. The three remaining categories (allocationconcealment, blinding of participants, incomplete outcomedata) had a concordance greater than κ=0.75.

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Figure 2 summarizes the risk of bias of the studies included inthis review. All the studies lacked information on at least one ofthe eight items of the methodological appraisal scale, and onestudy by Norlin lacked information on all eight items [28]. Onlythree of the 12 studies had three or less missing items [23–26,29]. For all of the included studies, the study protocols were notpublished and thus reporting bias could not be assessed. Lessthan half of the studies, 5 out 12, [25, 26, 31, 29, 30, 35]adequately reported their allocation sequence generation andonly 3 studies reported the procedure for allocation concealment[23–26, 29]. We also determined whether the RCTs adequatelyblinded the patients, the providers/personnel, and outcome as-sessors; we observed that this was done correctly in two, zero,and five studies, respectively. In the majority of studies (9/12),the outcome data was adequately reported.

For the majority of the studies (10/12), the authors did notdisclose details on co-interventions, such as the use of non-

steroidal anti-inflammatory drugs (NSAIDs) or exercise pro-grams following surgery, and it was therefore impossible todetermine whether these co-interventions constituted a sourceof bias or had influenced the outcome of the study. Further-more, the majority of the studies did not systematically dis-close complications and adverse effects of the treatments theycompared. The most common outcome measures used werethe constant score, the visual analogue scale (VAS) for pain,and the UCLA Shoulder Score [25, 26, 31, 32, 29, 28, 27, 35,36, 8].

Efficacy of acromioplasty compared to rehabilitation

In the four studies comparing a rehabilitation program to asurgical intervention, two different surgical techniques werecompared to exercise: arthroscopic acromioplasty in threestudies [23–26, 29] and open anterior acromioplasty in one

Fig. 1 Bibliographic search andstudy selection process for currentsystematic review

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Table1

Descriptio

nof

included

studies

Study

Participants

Interventio

nsandnumber

ofparticipants

Outcomemeasures

Mainresults

Methodological

quality

Broxetal.[23,24]

Patientswith

tendinopathy

for

3monthsandin

whom

conservativ

etreatm

entfailed

Group

1,arthroscopicsubacrom

ial

decompression

(n=45);group2,

supervised

exercises(n=30);group3,

placebodetunedlaser(n=50)

Neerscore(%

)At6

months,no

significantd

ifference

inchange

inscores,2.0%,95%

CI

(-1.4–5.4)

forgroup1comparedto

2;at2.5years,1.3%,95%

CI(0.8–2.2)

favoring

group1over

2

13/16(81.3)

Haahr

etal.[25]

Adults

diagnosedwith

shoulder

impingem

entsym

ptom

sthat

lasted

from

6monthsto

3years

Group

1,supervised

exercises

(n=43);group2,arthroscopic

subacrom

iald

ecom

pression

(n=41)

Constantscore

(%)

At3

,6,and

12months,no

significant

differencesin

change

betweengroups

(p=0.27,p

=0.76,p

=0.38)

9/16

(56.3)

Ketolaetal.[29]

Adults

with

chronicshoulder

impingem

entn

otrelievedby

conservativ

etreatm

ent

Group

1,supervised

exercise

(n=70);group2,arthroscopic

acromioplasty

follo

wed

byexercise

(n=70)

Self-reportedpain,

10cm

VAS

At2

years,no

significantd

ifference

inmeanchange

betweengroups,

0.2cm

,99%

CI(-1.61–1.14)

11/15(68.8)

Rahmeetal.[30]

Adults

with

subacrom

ial

impingem

entsyndrom

ewith

pain

foratleasta

year

Group

1,open

anterior

acromioplasty

(n=21);group2,exercise

regime(n=21)

Proportio

nof

patients

with

>50

%reduction

ofpain

(%)

At6

months,group1,57

%,group

2:33

%(p>0.05)

At1

2months,group1,76

%;g

roup

2,67

%(p>0.05)

10/16(62.5)

Husby

etal.[32]

Adults

with

clinically

demonstratedim

pingem

ent

syndromeformore

than

6months

Group

1,arthroscopicsubacrom

ial

decompression

(n=15);group2,

open

subacrom

iald

ecom

pression

(n=19)

UCLAscore(on35)

At6

,12,and96

months,no

significant

differencesbetweengroups

(p>0.05)

10/16(62.5)

Norlin

[28]

andLindh

andNorlin

[27]

Adults

with

clinically

demonstrated

impingem

entsyndrom

eGroup

1,open

acromioplasty

(n=10);group2,arthroscopic

subacrom

iald

ecom

pression

(n=10)

Activeflexion(°)

At3

months,group1hadsignificantly

morechange

inflexionthan

group2

(p=0.015);at2

years,no

significant

difference

(p>0.05)

8/16

(50)

Sachs

etal.[34]

Adults

diagnosedas

having

irreversiblestageIIim

pingem

ent

syndrome

Group

1,open

acromioplasty

(n=22);group2,arthroscopic

acromioplasty

(n=22)

Activeflexion(°)

At2

and6weeks,p

<0.05;at1

2,26,and

52weeks

(p>0.05)

7/16

(43.8)

Spangheletal.[35]

Adults

with

aclinicaldiagnosis

ofim

pingem

entsyndrom

eGroup

1,arthroscopicacromioplasty

(n=32);group2,open

acromioplasty

(n=30)

UCLAscore(on35)

At2

5.1months,no

significantd

ifference

inchange

betweengroups

(p=0.69)

8/16

(50)

T’Jonck

etal.[36]

Adults

diagnosed-assuffering

from

impingem

entstage

IIGroup

1,open

subacrom

iald

ecom

pression

(n=15);group2,arthroscopicsubacrom

ial

decompression

(n=17)

UCLAscore(on35)

At1

2months,group1,24.5±5.5and

group2,28

±5.6(p=0.046)

8/16

(50)

Henkusetal.[31]

Adults

diagnosedwith

subacrom

ialimpingem

ent

syndromebasedon

clinical

andim

agingtests

Group

1,arthroscopicsubacrom

ialb

ursectom

y(n=26);group2,debridem

entofsubacromial

bursafollo

wed

byacromioplasty

(n=31)

Constantscore

(%)

At2

.5years,no

significantd

ifference

betweengroups,group

1,13.9±17.9%

andgroup2,18.5±17.5

%,95%

CI

(-14.1–4.9)

11/16(68.8)

Ingvarsson

etal.[33]

Adults

with

adiagnosisof

chronicim

pingem

entsyndrom

eGroup

1,acromioplasty

(Neer’stechnique)

(n=10);group2,modificationof

Neer's

technique,delto

idisspared

(n=10)

Range

ofmotion(°)

Significantd

ifferences

inchange

inabductionat4weeks,group

1,15°andgroup2,55°(p<0.05);

at8weeks,group

1,40°andgroup2,

80°(p<0.05)

8/16

(50)

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study [25, 26, 29, 30, 23, 24]. In one of these RCTs, arthro-scopic acromioplasty was compared to both a supervisedexercise program and to a placebo (detuned laser treatment).Overall, three studies found that there was no significantdifferences between surgery and exercises in the treatment ofRC tendinopathy [25, 26, 29, 23, 24] and one study favoredsurgery [30].

In one trial, the patients undergoing arthroscopicacromioplasty also followed an exercise program post-operatively that was similar to the one administered to thepatients being treated by exercise only [29]. In the other twostudies, surgery patients also did exercises but the exerciseprotocol differed from the group being treated by exerciseonly [25, 26, 30]. Haahr et al. found that the arthroscopicsubacromial decompression group had an increase of 15.5 and19.9 % of its mean Constant score at 6 and 12 months post-operative while the supervised exercise group had increases of20.1 and 21.3 %, respectively [25, 26]. The differences be-tween treatments at 6 and 12 months were not significant (p=0.27 and p=0.76, respectively). The study by Haahr et al. alsoreported that patients who had undergone surgery tended tohave more sick payments and income transfers during the firstyear [25, 26]. Similarly, Ketola et al. concluded that arthro-scopic acromioplasty combined with exercise was no moreeffective than exercise alone, and this finding was based onthe observation that changes in the VAS pain scale were notsignificantly different between the two groups 2 years aftersurgery (a change of −3.7/10 for the exercises group and achange of −3.9/10 for the surgery group) (p>0.05) [29].Ketola et al. also found that the surgical treatment cost 1.6times more, on average, than physiotherapy alone. The studyby Rahme et al. measured treatment responses using a com-posite pain score (a sum of the VAS scores at rest, during“pour out of a pot” and “hand in neck” function tests) [30].The study showed that open anterior acromioplasty surgeryhad a higher proportion of patients who had achieved a 50 %reduction of their initial pain score after 6 months (57 %)compared to a standardized physiotherapy regimen (33 %)(p<0.05). After a year, the differential treatment benefit waseven wider: 76 % versus 19 %, in favor of the surgical group(p<0.0005) [30].

In one RCT that compared a supervised exercise programto arthroscopic subacromial decompression and to a placebo(detuned laser treatment), it was found that both arthroscopicsubacromial decompression and supervised exercise weresuperior treatments to placebo and that there were no signif-icant differences between these two treatments on the Neerscore at 6 months and at 2.5 years [24, 23]. There was,however, a significant difference in the proportion of patientshaving a Neer score higher than 80 % after 2.5 years with68% of patients having achieved this in the surgery group and61 % in the exercise group (p<0.01). This study also foundthat surgery cost about twice as much as supervised exercisesTa

ble1

(contin

ued)

Study

Participants

Interventio

nsandnumber

ofparticipants

Outcomemeasures

Mainresults

Methodological

quality

Tavernaetal.[8]

Adults

with

NeerstageII

impingem

entinwhom

6monthsof

conservativ

etreatm

enth

adfailed

Group

1,RF-basedplasma

microtenotomy(n=30);

group2,arthroscopic

subacrom

iald

ecom

pression

(n=30)

UCLAscore(on35)

At1

2months,no

significantd

ifference

betweengroups

(p=0.79)

10/16(63)

VASvisualanalogue

scale,UCLAscaleUniversity

ofCalifornia,Los

Angeles

scale

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to the public health care system (£720 vs. £390), but meanpatient sick leave was not significantly different between thethree groups after a period of 6 months (median of 3 months ofsick leave for all three groups).

Efficacy of arthroscopic acromioplasty compared to openacromioplasty

Five studies evaluated the efficacy of arthroscopicacromioplasty and compared it to open acromioplasty. Over-all, two studies found no differences between arthroscopic andopen acromioplasty [32, 36], two studies found that arthro-scopic acromioplasty yielded better results in the short-termfor shoulder flexion range of motion, but that both proceduresare comparable in the long-term [27, 28, 34], and one studyfavored open acromioplasty [35].

Husby et al. used the UCLA Shoulder Score as the primaryoutcome measure and found that there were no statistically

significant differences between arthroscopic acromioplastyand open acromioplasty 1, 3, 6, 12, and 96 months aftersurgery (p≥0.05) [32]. This study also found that the arthro-scopic procedure mean operating time was longer than theopen procedure mean operating time (82 vs. 50 min), and thatfollowing surgery, the patients in the arthroscopic group tookless time off work than those in the open group (5.7 vs.10 weeks), although no statistical comparison was performedon those results. T’Jonck et al. also compared arthroscopicacromioplasty and open acromioplasty and found that thearthroscopic group had a significantly better function at 1 yearas indicated by UCLA scores (24.5 vs. 28.3, p=0.046). How-ever, this study showed no significant differences for theConstant score, clinical tests (painful arc, speed, Jobe, lift -off), scapular position, or abduction and rotation shoulderstrength tests [36].

Sachs et al concluded that arthroscopic patients tended toregain flexion faster than the open surgery patients 6 weeks

Fig. 2 Risk of bias summary ofincluded studies using theCochrane risk of bias tool

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after surgery but that the open surgery patients caught up after3 months [34]. This study also found no statistically signifi-cant differences between the two groups at any time point interms of pain, shoulder strength, and other shoulder range ofmotions, and it also determined that patients took longer toreturn to work after open surgery compared to arthroscopicsurgery (54 vs. 36 days). In the trial by Spangehl et al., theauthors concluded that open acromioplasty was superior toarthroscopic acromioplasty in terms of pain and function(mean decrease in score for the arthroscopic acromioplastygroup was 2.88 and 4.32 for the open group on the VAS) butboth procedures were similar in terms of UCLA ShoulderScore, patient satisfaction, and shoulder strength [35]. Thedifference of 1.44 cm on the VAS scale between the twogroups may be considered clinically important as it exceedsthe minimal clinically important difference of 1.3 cm [37].

Another small trial (n=20) compared arthroscopicacromioplasty and open acromioplasty [27, 28]. At the 3-month follow-up, seven out of ten patients had limitation inabduction and flexion in the open group while all patients inthe arthroscopy group had regained full motion. The meanrange of motion in active abduction and active flexion weresignificantly different between the groups in favor of thearthroscopic group (p=0.004 and p=0.015, respectively). Noother outcomes were measured. After 2 years, there were nosignificant differences between the two groups of participants.The authors also stated that the arthroscopic procedure took anaverage of 40 min whereas the open procedure took an aver-age of 66 min and observed that post-operative recovery time(which was not defined by the authors) was 2.5 months(range: 2–3 months) in the arthroscopy group and 6.7 months(range: 3–16 months) in the open surgery group.

Efficacy of arthroscopic acromioplasty compared to othertype of surgeries

Taverna et al. compared arthroscopic acromioplasty to RF-based microtenomy [8]. The authors found that there were nostatistically significant differences between the VAS painscores, the ASES score, the Constant score, and the SF-36scores for the two groups. Another RCT compared arthro-scopic subacromial bursectomy alone to the debridement ofsubacromial bursa followed by acromioplasty and indicatedthat there was no significant difference between the Constantscore (69.6±18.2 % for bursectomy vs. 75.8±16.7 % fordebridement followed by acromioplasty, p=0.19) and theVAS pain and function between the two groups after afollow-up period averaging 2.5 years [31]. Another RCTlooked at acromioplasty (also referred to as “Neer’s proce-dure”) and compared it to a modification of this procedurewhere no T-shaped incision is made in the deltoid origin, andthus, the deltoid muscle is spared [33]. The authors found thatthe patients having undergone the modified technique tended

to have a greater mean shoulder abduction (120 ° vs. 135 °after 4 weeks and 145° vs. 160º after 8 weeks), and thisdifference was found to be statistically significant (p valuenot reported by the authors). There was no significant differ-ence in the range ofmotion for flexion, extension, and externaland internal rotations. No other variables, apart from range ofmotion, were measured in the two groups but the authors didnote that the mean operating time for the acromioplasty was44 min compared to 34 min for the modified technique.

Discussion

This systematic review synthesized evidence from 15 low tomoderate quality RCTs that evaluated the efficacy of surgeryin the treatment of RC tendinopathy. Only seven studiesreceived a methodological quality score higher than 50 % onthe Cochrane risk of bias tool, suggesting that the evidentiarypool remains weak and that future studies may result in achange in estimation of the effects of the treatments that wereviewed. Despite these limitations, we were able to makecautious conclusions based on the currently availableevidence.

Acromioplasty compared to exercise therapy

We conclude that there is moderate evidence indicating thatacromioplasty is not superior to exercises in the treatment ofRC tendinopathy. From the four studies that addressed thiscomparison, three studies, including one high-quality study[24, 23], agreed that there was no differential benefit foracromioplasty versus exercise alone [23–26, 29]. The studythat reported that surgery was superior based this conclusionon one non-validated functional assessment and did not pro-vide enough data for us to be able to determine if the differ-ence observed between the surgery and exercises group wasclinically important [30]. Since exercise often costs less, hasgeneral health benefits and a lower risk of adverse eventscompared to a surgical approach, patients with RCtendinopathy should be provided with a sufficient course ofexercise before a surgical intervention is considered. Thesefindings are consistent with other reviews that concluded thatexercise is effective at reducing pain and improving functionin patients with RC tendinopathy [38–40].

Adverse events and treatment costs were poorly addressedacross the available studies, primarily because the studiesincluded in this review did not formally focus on economicimpact and cost effectiveness of various interventions. Insituations where treatments have comparable effects, econom-ic considerations become important. Two studies found that asurgical approach was more expensive than exercises [23, 24,29], and one study also found that patients having undergonesurgery had more income transfers and took more sick leave

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than those having been treated by exercises [25, 26]. Theseresults suggest an economic benefit to conservative manage-ment both from the perspective of the patient and that ofsociety.

It is important to point out that because RC tendinopathy ismultifactorial, it remains unclear which subgroups of patientswill benefit from rehabilitation andwhich subgroupswill benefitmore from a surgical approach. Most of the RCTs in this reviewhave small sample sizes (less than 140 patients) and are unlikelyto be sufficiently powered to detect meaningful subgroup dif-ferences. It has been suggested that physical rehabilitation maybe more beneficial to patients with specific ultrasonographicacromiohumeral distance changes during arm elevation [41].Therefore, studies that identify specific deficits in musculoskel-etal structures and function, motor control, pain, and motion thatexist in RC tendinopathy, are needed before individualizedevidence-based treatment protocols can be devised.

Arthroscopic subacromial decompression compared to opensubacromial decompression

Regarding surgical techniques, we found eight studies thatcompared surgical procedures for the treatment of RCtendinopathy. Five of these studies compared arthroscopicsubacromial decompression to open subacromial decompres-sion. While the methodological quality of the studies is low tomoderate, the conclusion that can be drawn from these studiesis that both the open and the arthroscopic procedure havesimilar long-term (>12-month) outcomes. The only long-termdifference was that, in one study, it was found that the UCLAscore was higher after 1 year in the patients having undergonethe arthroscopic procedure; however, the difference was notclinically significant (3.8 units, which is below the minimalclinically important difference of 5 units) [36, 32]. Anotherreview has previously found that the outcomes from arthro-scopic subacromial decompression are similar to those fromopen subacromial decompression [42]. On a short-term basis,the patients who underwent arthroscopic subacromial decom-pression tended to fair better in terms of range of motion inflexion and abduction than the open acromioplasty patients:one pair of studies found that flexion was better in the arthro-scopic group in the first 3 months and another also showed thatpatients having undergone arthroscopic surgery had betterranges of motion in the first 3 months, although the open groupcaught up afterwards [34, 27, 28]. In the study by Sachs et alwhere they found that flexion was superior in the arthroscopicgroup in the first 3 months, the difference appeared to besuperior to the minimal clinically important difference of16 °, although the exact value is not available as the differencewas only reported graphically [43, 34].

Two studies concluded that patients having had arthroscop-ic subacromial decompression returned to work quicker thanthose having had open subacromial decompression but neither

study mentions if the difference between the groups wasstatistically significant [32, 34]. Two studies also measuredhow long each surgical procedure took and the results areconflicting: one study reports that the arthroscopic procedureis longer, whereas the other found that the open procedure islonger [32, 28]. We posit that surgery time may significantlyvary between surgeons and is probably dependent on thesurgeon training and related to one’s learning curve.

Despite the limitations in the study designs, multiple studiessuggested that arthroscopic subacromial decompression mightbe preferred over open subacromial decompression because it isas effective as the open procedure andmay offer faster recoveryof ranges of motion and faster return to work. In the case ofshoulder surgery, arthroscopic subacromial decompressionmaybe a longer and more technically demanding procedure, may becostlier, and may require special equipment and an experiencedsurgeon. When considering that the benefits of arthroscopicprocedures may only be short-term and the long-term outcomesmay be equivalent, the evidence suggests that recommenda-tions should be that arthroscopic subacromial decompressioncould be considered a good treatment option. More research isneeded to determine the difference in the amount of sick leavetaken by patients, in health care costs, and in operating timebetween the open and arthroscopic procedures since thesevariables may affect decision-making. Surgical practices canchange over time, and if arthroscopic procedures become moremainstream, the cost–benefit considerations may also change.Currently, one modality of surgical repair is not preferred overthe other due to lack of sufficient evidence [44].

Other surgical techniques

One study found that debridement of the subacromial bursafollowed by acromioplasty had similar results to arthroscopicsubacromial bursectomy alone [31]. Another study found thatthe modified Neer’s procedure is better than the originalNeer’s procedure and the difference was clinically important[33]. A study compared RF-based plasma microtenotomy andASD and found no differences between the two procedures[8]. For the procedures assessed in these studies, it is impos-sible to reach a different conclusion than the one made by theauthors because we only found one RCT that compares eachof the surgery procedures in question. Further research isneeded in order to consolidate our knowledge.

Strengths and limitations of current review

The value of our study lies in the comprehensive review of theliterature published to date on surgical procedures for rotatorcuff tendinopathy, in a thorough risk of bias assessment bytwo assessors and in an analysis limited to RCTs. Despite ourattempts to be rigorous, our study has substantial limitationsthat primarily arise from the nature of the existing pieces of

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evidence; many of the RCTs had a small sample size andmultiple potential sources of bias. Furthermore, given themany different surgical options available, the literature doesnot provide a comprehensive evaluation of all the differentoptions. Differences in outcome measures used further limitthe comparability across trials to the extent that we could notperform a meta-analysis, and thus, we recommend that futurestudies use a validated set of outcome measures in theiranalyses. Another potential limitation is that our search wasrestricted to French and English languages; it is thereforepossible that trials meeting our inclusion criteria exist in otherlanguages but were not included in this review .

Conclusion

Low- to moderate-grade evidence exists to suggest that exer-cise therapy is as effective as surgery for the treatment of RCtendinopathy. Low-grade evidence also suggests that arthro-scopic acromioplasty is as effective as open acromioplasty forthe treatment of RC tendinopathy and may yield better resultsin the short-term. Certain studies suggest that surgery may bemore expensive than exercise therapy alone. More research isneeded to determine which treatment approach results inpatients taking fewer sick leaves and returning to daily activ-ities earlier. More high-quality research using consistent andvalidated outcomes is required in order to be able to providetreatment guidelines to healthcare providers.

Disclosures None.

Appendix

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