The Case for Conservative Care in Shoulder Injury Treatment
When it comes to advanced imaging and surgical procedures, does the benefit really offset the cost?
Historically, rotator cuff tears and similar injuries had been approached through the lens of a biomedical model, whereby a structural abnormality is identified on a scan and addressed surgically to eliminate pain.
Today, however, we know that abnormalities are not always directly related to shoulder pain and physical therapy is a powerful option for many shoulder injuries. Knowing this, clinicians are now reconsidering the appropriateness and value of advanced imaging and surgical interventions as the first path of treatment for shoulder injuries.
PT Before Scans for Common Shoulder Pain
Shoulder pain has garnered additional attention in the last two decades due to its prevalence among baby boomers. Many consider rotator cuff degeneration to be the equivalent of gray hair and wrinkles.
The fact is, research shows partial or full-thickness tears are present in more than 50% of 70-year-olds and 80% of those over 80 years old. And such shoulder injuries can be present with no symptoms. As such, imaging results can sometimes be misleading because problems identified on the scan are often not necessarily directly correlated with symptoms.
Imaging in the first months following a shoulder injury is now considered unnecessary unless there is significant trauma. Instead, a more thoughtful, physical therapy-based approach is often first course of treatment for non-traumatic shoulder pain and shows promising results.
Surgery and Shots: Looking Beyond the Injury
The medical industry is also changing its perspective toward surgery and injections, recognizing that, like MRI scans, outcomes are not always so black and white. Research shows physical therapy can achieve in the same level of symptom improvement as both corticosteroid steroid injections and surgery for various shoulder issues but with a far smaller financial burden on patients and payers.
When appropriate, aggressive, and timely physical therapy is applied, many patients don’t need surgery at all. Although traumatic and acute tears often require more aggressive operative treatments, research suggests at least 50% of patients with shoulder pain can significantly improve without surgery.
As Dr. Philip W. McClure, PT, PhD, FAPTA said in a recent interview, “…surgery doesn’t always solve pain and there are a lot of people out there with tears that don’t have any pain at all.”
In the interview, McClure references a study by Kuhn, et al, that revealed 75% of patients with atraumatic rotator cuff injuries who participated in an exercise-based physical therapy program were able to avoid surgery. For the patients that followed their PT with surgery, the trial of conservative care did not result in a longer period of disability than it would have with a surgery-first approach.
A shift in shoulder injury treatment is underway. The cost-benefit ratio of surgery is being reevaluated, with the cost of the procedure and subsequent rehabilitation being weighed more thoughtfully. And conservative care treatment plans are becoming more prevalent.
What does the future hold? Many clinicians see physical therapy as first course of treatment becoming the gold standard. If shoulder injury treatment follows the lead of trends in low back pain, then rotator cuff patients can look forward to less invasive rehabilitation and lower medical costs in the years ahead.
Why does exercise show such promise for non-operative rotator cuff rehab and how is the move to conservative care impacting the wider medical community? Read more>>
To learn more about shoulder injury patient education, download the information sheet “I Have a Shoulder Injury. Now What?”.
Milgrom, C, et al. “Rotator-Cuff Changes in Asymptomatic Adults. The Effect of Age, Hand Dominance and Gender.” The Journal of Bone and Joint Surgery. British Volume., U.S. National Library of Medicine, 1 Mar. 1995, www.ncbi.nlm.nih.gov/pubmed/7706351.
“American College of Radiology ACR Appropriateness Criteria.” ACR Appropriateness Criteria, American College of Radiology, 1995, acsearch.acr.org/docs/69433/Narrative/.
Luks, Howard J. “When Should We MRI Shoulder Injuries?” Howard J. Luks, MD, Orthopedic Surgeon, 17 Jan. 2015, www.howardluksmd.com/orthopedic-social-media/mri-rotator-cuff-injuries/.
Rhon, Daniel I., et al. “One-Year Outcome of Subacromial Corticosteroid Injection Compared With Manual Physical Therapy for the Management of the Unilateral Shoulder Impingement Syndrome: A Pragmatic Randomized Trial.” Annals of Internal Medicine, American College of Physicians, 5 Aug. 2014, annals.org/aim/article/1892614/one-year-outcome-subacromial-corticosteroid-injection-compared-manual-physical-therapy.
Ryosa, Anssi, et al. “Surgery or Conservative Treatment for Rotator Cuff Tear: a Meta-Analysis.” Taylor & Francis, 6 July 2016, www.tandfonline.com/doi/abs/10.1080/09638288.2016.1198431?src=recsys&journalCode=idre20