Physical Therapy Combined With Subacromial Cortisone Injection Is a First-Line Treatment Whereas Acromioplasty With Physical Therapy Is Best if Nonoperative Interventions Fail for the Management of Subacromial Impingement: A Systematic Review and Network Meta-Analysis

ABSTRACT

Purpose

The purpose of this study was to construct an algorithm to optimize clinical outcomes in subacromial impingement based on current, high-level evidence.

Methods

A systematic review of all clinical trials on subacromial impingement published 1999-2020 was performed. Demographic, clinical, range of motion (ROM), and patient-reported outcome measures (PROMs) data was collected. Interventions were compared via arm-based Bayesian network meta-analysis in a random-effects model and treatments ranked via surface under the cumulative ranking (SUCRA) curves with respect to 3 domains: pain, PROMs, and ROM.

Results

A total of 35 studies comprising 3643 shoulders (42% females, age 50±5 years) were included. Arthroscopic decompression with acromioplasty ranked much higher than arthroscopic decompression alone for pain relief and PROM improvement, but the difference in absolute PROMs was not statistically significant. Corticosteroid injection (CSI) alone demonstrated inferior outcomes across all three domains (pain, PROMs, and ROM) with low cumulative rankings. Physical therapy (PT) with CSI demonstrated moderate-to-excellent clinical improvement across all three domains whereas PT alone demonstrated excellent ROM and low-moderate outcomes in pain and PROM domains. PT with non-steroidal anti-inflammatories or alternative therapies ranked highly for PROM outcomes and moderate for pain and ROM domains. Finally, platelet-rich plasma injections demonstrated moderate outcomes for pain, forward flexion, and abduction with very low-ranking outcomes for PROMs and external rotation.

Conclusions

Arthroscopic decompression with acromioplasty and PT demonstrated superior outcomes whereas CSI demonstrated poor outcomes in all three domains (pain, PROMs, and ROM). For patients with significant symptoms, the authors recommend PT with CSI as a first-line treatment, followed by acromioplasty and PT if conservative treatment fails. For patients with symptoms limited to 1-2 domains, the authors recommend a shared decision-making approach focusing on treatment rankings within domains pertinent to individual patient symptomatology.