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Shoulder procedures

The procedures below do not meet the standards of evidence for us to routinely fund them for our members. These guidelines include summaries of suggested alternatives and how funding decisions are made.

Procedure summaries

Arthroscopic subacromial decompression

A systematic review evaluating surgery for shoulder impingement found no clinically significant benefit to surgical intervention over non-operative treatment [1]

A multi-centre randomised trail found that subacromial decompression did not differ from arthroscopy alone [2]. Even though both surgeries provided symptom improvement, the difference was not clinically significant.

A systematic review into the procedure on patients with long-term subacromial pain syndrome found no important benefit when compared to both placebo surgery and exercise therapy [3]

Lastly, the Cochrane Review for surgery for rotator cuff disease also concluded there was no important benefit to people at one-year follow up [4]

Platelet-Rich Plasma Injection

The evidence supporting Platelet-rich plasma (PRP) injections use has been inconclusive.

The Cochrane review found that research evidence is insufficient to support its use in treating musculoskeletal soft tissue injuries [6]

A systematic review also concluded that PRP may not be beneficial for treatment of chronic rotator cuff disease [7]

A review of multiple studies regarding the use of PRP in the management of shoulder pathologies found minimal benefits for shoulder pain, function and healing [8]

Other shoulder injections

NICE guidance states that intra-articular corticosteroid injections should only be considered in addition to core treatments for relief of moderate to severe pain in patients with osteoarthritis [9]

NICE guidelines also do not recommend undertaking Hyaluronic acid injections

In the management of rotator cuff tendinopathy or impingement, an injection into the subacromial space can be considered for pain relief. But repeated injections may cause tendon damage [11]

The use of steroid injections depends upon the clinical indication that they are being used.

We will fund:

One steroid injection per shoulder, as a sole procedure, per year. This must be a GHJ or ACJ injection for degenerative disease.

If there is significant improvement, we may fund one further injection within a 12-month period.

Two injections in the management of rotator cuff pathology, but only where this is taking place alongside physiotherapy

For adhesive capsulitis we will fund an initial injection in order to facilitate physiotherapy. If this is not effective, we will fund one final injection of saline hydrodistension if appropriate [10]

We do not fund:

Hyaluronic acid injections, or injections of any other substances

An injection when it’s carried out in conjunction with another therapeutic procedure

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If you need further guidance on any of the above procedures, please submit a query form to get in touch with us.

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[1] Khan, M., Alolabi, B., Horner, N., Bedi, A., Ayeni, O. R., & Bhandari, M. (2019). Surgery for shoulder impingement: a systematic review and meta-analysis of controlled clinical trials. CMAJ open, 7(1), E149.

[2] Beard, D. J., Rees, J. L., Cook, J. A., Rombach, I., Cooper, C., Merritt, N., ... & Moser, J. (2018). Arthroscopic subacromial decompression for subacromial shoulder pain (CSAW): a multicentre, pragmatic, parallel group, placebo-controlled, three-group, randomised surgical trial. The Lancet, 391(10118), 329-338.

[3] Lähdeoja, T., Karjalainen, T., Jokihaara, J., Salamh, P., Kavaja, L., Agarwal, A.,& Ardern, C. L. (2020). Subacromial decompression surgery for adults with shoulder pain: a systematic review with meta-analysis. British journal of sports medicine, 54(11), 665-673.

[4] Karjalainen, T. V., Jain, N. B., Page, C. M., Lähdeoja, T. A., Johnston, R. V., Salamh, P., ... & Buchbinder, R. (2019). Subacromial decompression surgery for rotator cuff disease. Cochrane Database of Systematic Reviews, (1).

[5] Getting it Right First Time (2020) Getting it Right in Orthopaedics. Reflecting on success and reinforcing improvement. A follow up on the GIRFT national specialty report on orthopaedics. Retrieved from: https://gettingitrightfirsttime.co.uk/wp-content/uploads/2020/02/GIRFT-orthopaedics-follow-up-report-February-2020.pdf

[6] Moraes, V. Y., Lenza, M., Tamaoki, M. J., Faloppa, F., & Belloti, J. C. (2014). Platelet‐rich therapies for musculoskeletal soft tissue injuries. Cochrane Database of Systematic Reviews, (4).

[7] Hurley, E. T., Hannon, C. P., Pauzenberger, L., Fat, D. L., Moran, C. J., & Mullett, H. (2019). Nonoperative treatment of rotator cuff disease with platelet-rich plasma: a systematic review of randomized controlled trials. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 35(5), 1584-1591.

[8] Schneider, A., Burr, R., Garbis, N., & Salazar, D. (2018). Platelet-rich plasma and the shoulder: clinical indications and outcomes. Current reviews in musculoskeletal medicine, 11(4), 593-597.

[9] National Institute for Health and Care Excellence (2014). Osteoarthritis: care and management. NICE Clinical guideline. Retrieved from: nice.org.uk/guidance/cg177

[10] British Elbow & Shoulder Society (2015). BESS/BOA Patient Care Pathways: Frozen Shoulder. Shoulder & Elbow. Vol 7(4) 299-307.

[11] British Orthopaedic Association (2014) Commissioning Guide: Subacromial Shoulder Pain. Retrieved from: https://www.boa.ac.uk/uploads/assets/uploaded/f4bfe04a-0450-4eab-b9acad9dbb5d8c86.pdf

All information accurate as of February 2023

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Shoulder procedures

Procedure summaries

Arthroscopic subacromial decompression

Evidence

Funding decision

Platelet-Rich Plasma Injection

Evidence

Funding decision

Other shoulder injections

Evidence

Funding decision

Recommendations

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References

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