Our guidelines to
OverviewThe below procedures do not meet the standards of evidence required for us to routinely fund them for our members. We've included summaries of selected research, up to date guidelines and other information. Please be advised that if these procedures are performed, we may ask for more information. We may also contact consultants whose practice isn’t in line with current guidelines.
Arthroscopic subacromial decompression
A multi-centre randomised trial found that subacromial decompression did not differ from arthroscopy alone (2). Even though both surgeries provided more symptom improvement than no treatment, the difference was not clinically significant.
Another systematic review assessed the role of subacromial decompression surgery in patients with long-term subacromial pain syndrome (3). The findings had no important benefit when compared to both placebo surgery and exercise therapy.
Lastly, the Cochrane Review for surgery for rotator cuff disease also concluded there was no benefit to people at one year follow up (4). There was no improvement in pain, function or quality of life when compared with placebo surgery.
Platelet-Rich Plasma Injection
A systematic review also concluded that PRP may not be beneficial for non-operative treatment of chronic rotator cuff disease (7). Also, the review suggested that PRP use did not result in improved outcomes in function, pain or range of movement.
On the other hand, another systematic review evaluating the role of PRP in improving pain and function in rotator cuff tears did suggest that it may positively affect clinical outcomes (8). However, due to limited data and poor methodology they could not make firm conclusions over its usage.
Lastly, 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 (9). Overall, the evidence remains unclear with more randomised controlled trials needed to further evaluate its use.
Other Shoulder Injections
In the management of rotator cuff tendinopathy or impingement, an injection into the subacromial space can be considered to achieve pain relief but repeated injections may cause tendon damage (12).
We’ll fund one steroid injection per shoulder as a sole procedure per year, but only for GHJ or ACJ injections for degenerative disease, and not on an ongoing basis for regular pain management. If there is significant improvement, we may fund one further injection within a 12 month period.
For rotator cuff pathology an initial injection is often used alongside physiotherapy and may be repeated in order to facilitate their ongoing therapy. We will fund two injections in the management of rotator cuff pathology, but only where this is taking place alongside physiotherapy.
Similarly for adhesive capsulitis we will fund an initial injection in order to facilitate physiotherapy and if this is not effective we will fund a one final injection of saline hydrodistension if appropriate (11).
We don’t fund hyaluronic acid injections or injections of other substances, in line with NICE guidance. We also won’t fund an injection when it’s carried out in conjunction with another therapeutic procedure, where we would expect this to be part and parcel of the treatment offered.
• Education, rest, NSAIDs, simple analgesia
• Appropriate structured physiotherapy with goal setting for 6 weeks.
If you have a questionWe understand that there are certain clinical scenarios, as well as variation in opinion, where these orthopaedic procedures may be recommended. So, if you are in any doubt, please contact us before you recommend the procedure and we’ll do all we can to find an acceptable solution for you and our member.
View our references
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
Platelet-Rich Plasma Injection
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. Chen, X., Jones, I. A., Togashi, R., Park, C., & Vangsness Jr, C. T. (2020). Use of platelet-rich plasma for the improvement of pain and function in rotator cuff tears: a systematic review and meta-analysis with bias assessment. The American journal of sports medicine, 48(8), 2028-2041.
9. 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.
10. National Institute for Health and Care Excellence (2014). Osteoarthritis: care and management. NICE Clinical guideline. Retrieved from: nice.org.uk/guidance/cg177
11. British Elbow & Shoulder Society (2015). BESS/BOA Patient Care Pathways: Frozen Shoulder. Shoulder & Elbow. Vol 7(4) 299-307.
12. British Orthopaedic Association (2014) Commissioning Guide: Subacromial Shoulder Pain. Retrieved from: https://www.boa.ac.uk/uploads/assets/uploaded/f4bfe04a-0450-4eab-b9acad9dbb5d8c86.pdf