Surgical or conservative treatment for impingement of the rotator cuff?

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Your patient is a 45-year old painter and employee working for a construction company. He experienced a sharp and severe pain in his dominant right shoulder while painting a ceiling. After six weeks, the pain persisted limiting the mobility of the arm and the patient's capacity to work. A physician assessing the patient diagnosed a subacromial impingement syndrome and excluded a full-thickness rotator cuff tear (full thickness tears refers to the entire separation or avulsion of the tendon from the bone) and other differential diagnoses by ultrasound. Following the recommendations of the 2014 Guideline for Diagnosis and Treatment of Subacromial Pain Syndrome by the Dutch Orthopaedic Association, the surgeon recommended a conservative treatment with a subacromial injection with corticosteroids and physiotherapy. The physiotherapy focused on muscle strengthening, scapular stabilization, stretching and flexibility exercises, and proper posture.¹ After five months and despite some improvement in pain and function, the patient was still not able to return to work. He decided to consult a second orthopedist who suggested a surgical procedure (subacromial decompression). The patient asks for your advice on the benefits and implications of having surgery versus conservative treatment to improve shoulder pain, function and his ability to work. Below we summarize the findings from a recent Cochrane review on the use of surgical or conservative treatment for impingement syndrome of the shoulder and its impact on outcomes such as, pain, shoulder function, quality of life, participants' assessment of success, participation on work and recreational activities, adverse events, serious adverse events, and treatment failure. …