Subacromial decompression – Does it work?

The shoulder

The shoulder is a ball (head of the humerus) and socket (glenoid cavity of the scapula) joint. There is a space between the acromion (which is part of the scapula) and the top surface of the humeral head, which is called the subacromial space (its height is 1-1.5 cm). This space is outlined by the acromion, coraco-acromial ligament and the coracoid process (which are parts of the scapula), which makes up the roof of the shoulder, and by the humeral head which makes up the floor of the shoulder. In this space are located tendons called the rotator cuff.

When the rotator cuff tensons, mainly the supraspinatus tendon, rubs against the roof of the shoulder over and over, at one point it will get inflamed and irritated and as a result it will cause pain. This is a common disorder of the shoulder, called Subacromial Impingement Syndrome (SAIS).

The SAIS can start suddenly or come on gradually. The symptoms are: pain in the top and outer side of your shoulder, which is worse when you lift your arm, especially when you lift it above your head; pain or aching at night, which can affect your sleep; weakness in your arm.

Normally people with the SAIS try first the conservative treatment (nonsteroidal antiinflammatory drugs, physiotherapy, steroid injections, etc…) and if it doesn’t work they go for surgery, Arthroscopic Subacromial Decompression (ASD). The operation aims to increase the size of the subacromial area and reduce the pressure on the tendons. It involves cutting the coraco-acromial ligament and shaving away the bone spur on the acromion bone. This allows the tendons to heal.

Does arthroscopic subacromial decompression (ASD) really work?

A study carried out in 2018 (Subacromial decompression versus diagnostic arthroscopy for shoulder impingement: randomised, placebo surgery controlled clinical trial – BMJ 2018 ;I need to set up external and internal links, maybe I need business account) assessed the efficacy of arthroscopic subacromial decompression (ASD) by comparing it with diagnostic arthroscopy (a placebo surgical intervention), and with
a non-operative alternative, exercise therapy.

122 patients with subacromial pain and unresponsive to conventional treatment; Age 35-65; Pain for 3 or more months.

59 patients ASD (arthroscopic subacromial decompression)

63 patients DA (diagnostic arthroscopy – placebo)


Arthroscopic subacromial decompression provided no benefit over diagnostic arthroscopy at 24 months in terms of pain and functional outcomes.

It is important to know that with the advent of arthroscopy, the number of subacromial decompression procedures has increased many times between the 1980s and the 2010s. This studyArthroscopy and the Dramatic Increase in Frequency of Anterior Acromioplasty from 1980 to 2005: An Epidemiologic Study -2010(I need to put an external link) reported that The incidence of anterior acromioplasty increased over time with the crude rate of 3.3 per 100,000 in 1980 to 1985 to 19.0 per 100,000 in 2000 to 2005 in the US. The overall incidence was higher in men than women, with the highest incidence in patients age 41 to 64 years.

Another study (external link) – Subacromial decompression surgery for adults with shoulder pain: a clinical practice guideline – BMJ 2019 compared ASD with conservative treatment (physical therapy, exercise programmes, NSAIDs, and steroid injections) in adults with atraumatic shoulder pain for more than 3 months diagnosed as subacromial pain syndrome (SAPS), also labelled as rotator cuff disease.

Results: Surgery did not provide important improvements in pain, function, or quality of life compared with placebo surgery or other options (after 1 year). Frozen shoulder may be more common with surgery.

Practical issues with surgery:

After surgery, 2 weeks off work are typically needed;

Avoid heavy lifting for one to three weeks, overhead activities for 3 months

(Double check with Baby)



What is osteoporosis?

Osteoporosis is a disease that is characterized by low bone mass, deterioration of bone tissue, and disruption of bone microarchitecture: it can lead to compromised bone strength and an increase in the risk of
fractures. Osteoporosis is a risk factor for fracture just as hypertension is for stroke.

It was estimated that the number of patients worldwide with osteoporotic hip fractures is more than 200 million. According to recent statistics from the International Osteoporosis Foundation, worldwide, 1 in 3 women over the age of 50 years and 1 in 5 men will experience osteoporotic fractures in their lifetime.

Osteoporosis has no clinical manifestations until there is a fracture. Fractures cause important morbidity; in men, in particular, they can cause mortality-

Fortunately, a well designed exercise program can help to counterbalance the losses in bone density that occur with age and may even allow people to slightly increase their bone density. 

What is the best exercise to get my bones stronger?

The best exercises to improve your bone density are weight training and weight-bearing exercises (eg. walking, jogging, etc…). We need to feed our bones with load. When a bone is loaded, this activates the production of bone building cells (osteoblast), which are responsible for the synthesis and mineralization of bone.

Exercise to promote bone and muscle strength:

Muscle strengthening – resistance exercise

  • Frequency: at least 2-3 times/week (non-consecutive days)
  • Duration: aim for 20-30 minutes on exercises that target legs, arms and spine
  • Intensity/Time: 1-3 sets of 8-12 repetitions of each exercise
  • Type: 1 exercise per body part

Weight bearing exercise with impact

The recommendations are:

  • For people with osteoporosis but without fractures: about 50 minutes moderate impacts on most days (jumps, skips, jogs, hops, etc.)
  • For people who have spinal fractures or are unable to do moderate impact: 20 minutes lower impact exercises on most days (walks, brisk walking, marching, stair climbing, etc.)

Balance exercise is also recommended, up to 20 minutes per day. Balance needs to be challenged in order for it to be effective and balance exercises must be maintained as balance can decrease quickly.

What about cycling, and swimming?

These activities are not weight-bearing and don’t provide impact. They may strengthen muscles to some extent but because the weight of your body is held by the water or your bike, there isn’t much force going through to your bones. It’s probably not enough to promote bone strength.

What about walking?

Walking is a form of exercise such as cycling and swimming, and it doesn’t provide enough of a loading stimulus to stimulate bone growth.


With an aging population and longer life span, osteoporosis is increasingly becoming a global epidemic. Therefore, increasing awareness among healthcare workers, which, in turn, facilitates increase awareness of the normal populace, will be effective in preventing this epidemic.


Unilateral shoulder pain and bilateral MRI findings

Magnetic resonance imaging (MRI) is commonly used to diagnose structural abnormalities in the shoulder. However, clinical findings may not be the source of symptoms

In this study were evaluated over 100 individuals who reported unilateral shoulder pain, with no signs of adhesive capsulitis, no substantial range-of-motion deficit, no history of upper-limb fractures, no repeated shoulder dislocations, and no neck-related pain. All partecipants had MRI (interpreted by an orthopedic shoulder surgeon and a musculoskeletal radiologist) of both symptomatic and asymptomatic shoulders.


Abnormal MRI findings were observed in both shoulders.

Rotator cuff tendinopathy, partial-thickness tear, full-thickness tear, labrum alterations, acromial morphology (Type I, II, III), long head of biceps alterations, AC joint alterations, subacromial fluid, fatty infiltration, glenohumeral osteoarthritis.

Only the frequencies of full-thickness supraspinatus tendon tears and glonohumeral osteoarthritis (OA) were higher (about 10%) in the symptomatic shoulder according to the surgeon’s findings only.

Agreement between the musculoskeletal radiologist and shoulder surgeon ranged from slight to moderate.


Most abnormal MRI findings were not different in frequency between symptomatic and asymptomatic shoulders.

Consider additional factors to help explain patients pain – Todd Hargrove


Explain Back Pain

Explain back pain is a great book written by David S. Butler and G. Lorimer Moseley in 2013. It is an evidence based book designed for therapists, patients and students. I have made some mind mapping about it. I hope you find it useful to review some concepts or study. For who don’t know, you have to read the mind map clockwise.


Knee arthroscopy – Does it work?

Romina Brignardello-Petersen et al., BMJ 2017,

Knee arthroscopy versus conservative management in patients with
degenerative knee disease: a systematic review

Over the long term, patients who undergo knee arthroscopy versus those who receive conservative management strategies do not have important benefits in pain or function.

Patients and their healthcare providers must trade-off the marginal
short-term benefits against the burden of the surgical procedure (pain, swelling, limited mobility, restriction of activities, over a period of 2–6 weeks).

Raine Sihvonen et al. 2017,

Arthroscopic partial meniscectomy versus placebo surgery for a degenerative meniscus tear: a 2-year follow-up of the randomised controlled trial

Arthroscopic partial meniscectomy (APM) is one of the most common orthopaedic operations, with an incidence that has increased steadily from 1990s until late 2010s. Most APMs are carried out in middle-aged and older patients with knee symptoms and degenerative knee disease. Several recent
meta-analyses based on randomised controlled trials (RCTs) have failed to show a treatment-benefit of APM over conservative treatment or placebo
surgery for these patients.


In this 2-year follow-up of patients without knee osteoarthritis but with symptoms of a degenerative medial meniscus tear, the outcomes after
APM were no better than those after placebo surgery. No evidence could be found to support the prevailing ideas that patients with presence of mechanical symptoms or certain meniscus tear characteristics or
those who have failed initial conservative treatment are more likely to benefit from APM.

Reed A C Siemieniuk, 2017,

Arthroscopic surgery for degenerative knee arthritis and meniscal tears: a clinical practice guideline

Approximately 25% of people older than 50 years experience knee pain from degenerative knee disease.

What is degenerative knee disease?

Knee disease is an inclusive term, which many consider synonymous with osteoarthritis. We use the term degenerative knee disease to explicitly include patients with knee pain, particularly if they are >35 years
old, with or without:

  • Imaging evidence of osteoarthritis (OA)
  • Meniscus tears
  • Locking, clicking, or other mechanical symptoms except persistent objective locked knee
  • Acute or subacute onset of symptoms

Most people with degenerative arthritis have at least one of these characteristics. The term degenerative knee disease does not include patients having recent debut of their symptoms after a major knee trauma with acute onset of joint swelling (such as haemarthrosis).

Management options include weight loss if overweight, a variety of interventions led by physical therapists, exercise, oral or topical pain medications such as non-steroidal anti-inflammatory drugs, intraarticular corticosteroid and other injections, arthroscopic knee surgery, and knee replacement or osteotomy.

What you need to know

There is a strong recommendation against the use of arthroscopy in nearly all patients with degenerative knee disease, based on systematic reviews. This recommendation applies to patients with or without imaging evidence of osteoarthritis, mechanical symptoms, or sudden symptom onset.

Arthroscopic knee surgery for degenerative knee disease is the most common orthopaedic procedure in countries with available data and on a global scale is performed more than two million times each year. Arthroscopic procedures for degenerative knee disease cost more than $3bn per year in the US alone.


Back Pain – Mythbuster

Email CSP if I can share this



Sciatica (also called radicular pain) is commonly used to describe radiating leg pain. It is caused by inflammation or compression of the lumbosacral
nerve roots (L4-S1) forming the sciatic nerve. Sciatica can cause severe discomfort and functional limitation.

People with sciatica usually describe aching and a sharp leg pain radiating below the knee and into the foot and toes. The pain can have a sudden or slow onset and varies in severity. Most people report coexisting low back pain. Disc herniations affecting the L5 or S1 nerve root are more common and cause pain at the back or side of the leg and into the foot and toes. If L4 root is affected, pain is localised to the front and lateral side of the thigh. Tingling or numbness and loss of muscle strength in the same leg are other symptoms that suggest nerve root involvement.

How common is sciatica?

In the UK about 60% of patients with back and leg pain were clinically diagnosed with sciatica.

How is sciatica diagnosed?

Sciatica is a clinical diagnosis based on the person’s symptoms and findings on examination. Symptoms and signs suggesting sciatica:

  • Unilateral leg pain more severe than low back pain;
  • Pain most commonly radiating posteriorly at the leg and below the knee;
  • Numbness and/or paraesthesia in the involved lower leg;
  • Neurological deficit associated with the involved nerve root (muscle weakness/absence of tendon reflexes/sensory deficit);
  • Positive neural tension test with provocation of pain in the affected leg (straight leg raise test/femoral nerve test/slump test).

Role of imaging

  • Routine imaging is not advised in people with non-specific low back pain with or without sciatica
  • Disc herniation is a common age related finding
  • Consider imaging if symptoms progress for more than 12 weeks, or if the person has progressive neurological deficits (signs of urinary retention or decreased anal sphincter tone ) or worsening pain

Conservative treatment

  • Encourage patients to remain active and avoid bed rest

What is the prognosis?

  • Most people experience an improvement in symptoms over time with either conservative treatment or surgery
  • For disabling symptoms lasting longer than 6 weeks with a lack of response to non-operative management, specialist referral (rheumatologist, rehabilitation physician, spinal surgeon) can also be considered
  • Laminectomy surgery for radiculopathy may shorten the duration of symptoms, but outcomes at 12 months are similar to non-operative treatment and surgery is associated with increased risk of further surgery
  • Decompression surgery for central lumbar canal stenosis may improve symptoms, but there is a lack of high -quality evidence for its superiority over non-operative management


  • Diagnosis and treatment of sciatica, bmj 2019;
Health & Education

Keep yourself active – Why?

Globally people are becoming less active, in part of the life is getting busier, in part of comfort we have such as we prefer driving to work even if it is just 5 minutes from home, due to covid-19 there is smart work and a lot of people work from home, due to technology you don’t need to go out for dinner, just order some take away. (write better with Vanessa).

The World Health Organization (WHO) in 2010 identified physical inactivity as the fourth leading risk factor for global mortality (6% of deaths globally).

This follows high blood pressure (13%), tobacco use (9%) and high blood glucose (6%). Overweight and obesity are responsible for 5% of global mortality.

Insufficient physical activity is a key risk factor for noncommunicable diseases (NCDs) such as cardiovascular diseases, cancer and diabetes.

Physical activity has significant health benefits and contributes to prevent NCDs.

Globally, 1 in 4 adults is not active enough.

More than 80% of the world’s adolescent population is insufficiently physically active.

How much of physical activity is recommended (for adults aged 18-64 years)?

  • Should do at least 150 minutes of moderate-intensity physical activity throughout the week, or do at least 75 minutes of vigorous-intensity physical activity throughout the week, or an equivalent combination of moderate- and vigorous-intensity activity.
  • For additional health benefits, adults should increase their moderate-intensity physical activity to 300 minutes per week, or equivalent.
  • Muscle-strengthening activities should be done involving major muscle groups on 2 or more days a week.

Moderate aerobic activity: walking, riding a bike, dancing, hiking, doubles tennis, water aerobics, rollerblading.

Vigorous activity: jogging or running, swimming fast, riding a bike fast or on hills, sports (football, rugby, netball, hockey,…), aerobics, gymnastics, martial arts.

In general, 75 minutes of vigorous intensity activity can give similar health benefits to 150 minutes of moderate intensity activity.

It is important to know that vigorous intensity activity increases our cardiorespiratory fitness which allows us to live longer (Jama study – external link).

Cardiorespiratory Fitness and long -term mortality – Jama 2018

Cardiorespiratory fitness is an indication of a person’s overall physical health, and improving it should be the aim of everyone because it helps us to live better and more than anything longer. (Review with Vanessa).

A study – Cardiorespiratory Fitness and long -term mortality – Jama 2018 (external link) pubblished in 2018 by Jama, compares cardiorespiratory fitness long-term with mortality. The take away from this study are:

  • Cardiorespiratory fitness is inversely associated with long-term mortality.
  • High aerobic fitness is associated with the greatest survival and is associated with benefit in older patients and those with hypertension.
  • Cardiorespiratory fitness is a modifiable indicator of long-term mortality, and health care professionals should encourage patients to achieve and maintain high levels of fitness.

Think how to link push – ups in the blog

Get better at Push-Ups (Justin Yang et al. 2019, JAMA)

This study showed the association between Push-up exercise capacity
and future cardiovascular events among active adult men.

Cardiovascular disease (CVD) remains the leading cause of mortality worldwide. Robust evidence indicates an association of increased physical fitness with a lower risk of CVD events and improved longevity.


  • This study of 1104 occupationally active adult men (mean age 39) found a significant negative association between baseline push-up capacity and incident cardiovascular disease risk across 10 years of follow-up.
  • Participants able to complete more than 40 push-ups were associated with a significant reduction in incident cardiovascular disease event risk compared with those completing fewer than 10 push-ups.

Low Back Pain: a major global challenge

The Lancet – 2018

Almost everyone will have low back pain at some point in their lives. It can affect anyone at any age, with the biggest increase seen in low-income and middle-income countries. Disability due to back pain has risen by more than 50% between 1990 and 2015.

For nearly all people with low back pain, it is not possible to identify a specific cause (non-specific low back pain). Only a small proportion of people have a well understood pathological cause – eg, a vertebral fracture, malignancy, or infection (specific low back pain).

Key messages:

  • Low back pain is an extremely common symptom.
  • Most episodes of low back pain are short-lasting with little or no consequence
  • People with physically demanding jobs, physical and mental comorbidities, smokers, and obese individuals are at greatest risk of reporting low back pain.
  • Disabling low back pain is over-represented among people with low socioeconomic status, where possibilities for job modification are limited.
  • Lifestyle factors, such as smoking, obesity, and low levels of physical activity, that relate to poorer general health, are also associated with occurrence of low back pain episodes.

Prevention and Treatment of low back pain

  • There is lack of evidence for prevention of low back pain: back belt, ergonomic furniture, work-place education, no-lift policies, mattresses, lifting device. The only known effective interventions (based on low to moderate quality evidence) are exercise combined with education, or exercise alone.
  • Do not recommend passive electrical or physical modalities, such as ultrasound, transcutaneous electrical nerve stimulation (TENS), traction, short-wave diathermy, and back support for low back pain.
  • No one exercise seems superior to another.
  • Some guidelines do not recommend passive therapies, such as spinal manipulation or mobilisation, massage, and acupuncture, some consider them optional, and others suggest a short course for patients who do not respond to other treatment.
  • Spinal imaging is inappropriate for non-specific low back pain (W. Brinjikji at el. 2015).
  • Interventional therapies (e.g. injections, surgery and medicines) have a limited role for non-specific low back pain.
  • Non-pharmacological treatments in the form of advice, reassurance, and activity should be the first line treatmen option for non-specific low back pain.
  • Paracetamol is not recommended.
  • Consider oral non-steroidal anti-inflammatory drugs (NSAIDs), taking into account potential risks, and if using them, prescribe the lowest effective dose for the shortest possible time.
  • Routine use of opioids is not recommended, since benefits are small and substantial risks exist, including overdose and addiction. If used, they should only be in carefully selected patients, for a short duration, and with appropriate monitoring.



Osteoarthritis (OA) is the most common form of arthritis, affecting an estimated 302 million people worldwide, and is a leading cause of disability among older adults. The knees, and hips, are the most commonly affected joints. OA leads to pain, stiffness, swelling, and loss of normal joint function (2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee).

Recommendations for physical, psychosocial, and mind-body approaches for the management of osteoarthritis of the knee, and hip.

Strongly recommended: Exercise, Weight loss, Tai Chi, Knee brace (tibiofemoral knee brace), Cane, Self-efficacy and self-management programs.

Conditionally recommended: Yoga (for the knee), Cognitive Behavioral Therapy, Balance Training, Patellofemoral Braces, Acupuncture, Thermal Interventions, Kinesiotaping (for the knee).

Strongly recommeded against: TENS (transcutaneous electrical nerve stimulation)

Conditionally recommeded agaist: Modified Shoes, Wedged Insoles, Massage, Manual Therapy with / without exercise, Pulsed Vibration Therapy

Knee X-ray and Pain

Radiographs have long been considered as the reference standard for the assessment of OA, for more than four decades. To date, the majority of studies have reported that radiographic OA (ROA) is poorly correlated with knee symptoms, and most risk factors for ROA are not strong predictors of knee pain. Pain perception is complex, however, and knee pain is frequently associated with non-OA variables, such as psychosocial factors, education, economic statusas well as local pathology (Radiographic Knee Osteoarthritisand Knee Pain: Cross-sectionalstudy from Five Diferent Racial/Ethnic Populations 2018).

Running does not increase symptoms or structural progression in people with knee osteoarthritis – Tom Goom (Physio Network 2018)

We can help reassure such people that they can continue to run without fear and that it may even lead to improvement in sympom“.

The current research in OA suggests 3 important things:

  1. Arthritic change within knee joints is very common even in those without pain, for example a study from Geurmazi et al. 2012, found 68% of people with no pain had evidence of cartilage damage on MRI.
  2. Running doesn’t appear to increase the risk of developing hip or knee arthritis.
  3. Running with knee OA doesn’t seem to hasten disease progression or worsen symptoms over a period of time.

Prescribed Exercise For Knee Osteoarthritis Via Skype? – R. S. HINMAN et al. 2017, American College of Rheumatology ( article reviewed by Dr Jarod Hall, Physio Network)

Key points

  • The finding of this study demostrate that both patients and physical therapist had mostly positive experience using Skype as a service delivery model for physical therapist-supervised exercise management of moderate knee osteoarthritis (OA).
  • Patients and therapists found skype consultations for knee OA to be efficient, effective, empowering, and surprisingly personal.