Can shoulder arthroscopy work?

The CSAW trial

If you or someone you know is suffering from shoulder pain, making an informed decision about which treatment options to pursue can be difficult. Surgery is a frequently recommended option to treat a condition still commonly known as subacromial impingement.

This landmark clinical trial evaluated the effectiveness of subacromial decompression surgery, a commonly performed procedure, comparing it to a placebo (fake) surgery as well as no treatment. The findings pose a real challenge to the traditional understanding and management of subacromial shoulder pain.

Inclusion and exclusion criteria

Who was included?

  • Subacromial pain for 3+ months
  • Intact rotator cuff tendons
  • Eligible for arthroscopic surgery
  • Completed a nonoperative program consisting of exercise and 1+ injection

Who was excluded?

  • Full thickness rotator cuff tear
  • Partial thickness tears were recorded but not excluded

313 subjects

Split evenly

into 3 groups

Decompression

Real surgery

53
Age

51%
Female

Arthroscopy

Placebo surgery

54
Age

50%
Female

No treatment

Control group

53
Age

50%
Female

Operated at
30 sites
Treated by
38 surgeons

Decompression is no better than sham.

Both surgical groups improved their Oxford Shoulder Score* compared to those who underwent no treatment, but decompression did not outperform arthroscopy.

* The Oxford Shoulder Score is a 48-point questionnaire that measures shoulder function.

Implications

One interpretation

Both decompression as well as arthroscopy are effective and could be considered as treatment strategies for subacromial pain.

More likely

Surgery, although statistically better than no treatment, doesn't provide subacromial pain patients with a clinically meaningful benefit.

Shoulder pain patients:
Bring this study up with your trusted health professional. Ask them about the risks, benefits, and evidence behind your different treatment options. Collaborate to make an informed decision that's right for you.

Health professionals:
Invasive therapies can be powerful, but the validity of established procedures should not be taken for granted. Talk with your patients about the evidence regarding surgery for their condition. Collaborate to make an informed decision that's right for them.

References

Beard DJ, Rees JL, Cook JA, et al. Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW): a multicentre, pragmatic, parallel group, placebo-controlled, three-group, randomised surgical trial. Lancet. 2018;391(10118):329-338.

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