RAG rating
n/a
Document type
Clinical policy
Place
Hertfordshire and West Essex ICB
Output type
Clinical Policies & Evidence-based Interventions
Document
Download

Shoulder Arthroscopy

v1.1

This policy covers the use of shoulder arthroscopy to treat a number of different conditions including labral tears, rotator cuff repair, adhesive capsulitis, and non-traumatic joint instability.

Arthroscopic shoulder decompression for subacromial shoulder pain is outside of the scope of this policy. Please refer instead to the national EBI policy at https://ebi.aomrc.org.uk/  and the supplementary local policy on Arthroscopic shoulder decompression for subacromial shoulder pain.

Definition

An arthroscopy is a form of keyhole surgery that is used to look inside a joint and repair any damage that has occurred. An arthroscopy has two main uses:

  • Treatment – an arthroscopy can be used to repair damage to the joint.
  • Diagnosis – an arthroscopy can help diagnose problems with the joint, such as joint pain, stiffness, or limited range of joint movement.

The commissioners do not fund the use of shoulder arthroscopy for diagnostic purposes; radiological investigations should be used for this.

Threshold Eligibility Criteria

The patient will qualify for shoulder arthroscopy and treatment if clinically indicated, when they meet one of the following criteria:

  • Full thickness rotator cuff tear as demonstrated by clinical symptoms and radiological imaging

OR

  • Significant superior labrum anterior posterior (SLAP) tear as demonstrated by clinical symptoms and radiological imaging

OR

  • Partial thickness rotator cuff tear as demonstrated by clinical symptoms and radiological imaging which has not responded to 3 months of conservative management

OR

  • Minor (type I*) SLAP tear as demonstrated by clinical symptoms and radiological imaging which has not responded to 3 months of conservative management

OR

  • *Adhesive capsulitis demonstrated by clinical symptoms which has not responded to 6 months of conservative management

OR

  • *Adhesive capsulitis demonstrated by clinical symptoms and in the view of the treating consultant is having an extraordinarily severe impact on quality of life, and which has not responded to conservative management including corticosteroid injection where clinically appropriate.

OR

  • Non-traumatic shoulder joint instability that has not responded to 6 months of conservative management

OR

  • Traumatic shoulder joint instability alongside relevant conservative management as clinically appropriate.

Conservative Management

The conservative management to be attempted prior to referral includes the following:

  • Activity modification
  • Physiotherapy and exercise programme
  • Oral analgesics, including NSAIDs (unless contraindicated)
  • Steroid injections to the affected part of the joint where clinically appropriate

In the above criteria radiological imaging mentioned is to be organised by secondary care physicians as appropriate. Clinical symptoms are to be evaluated by both primary and secondary care physicians.

*Sydner classification (Synder SJ, Karzel RP, Del Pizzo W, et al. SLAP lesions of the shoulder. Arthroscopy 1990; 6; 274-279)

Frozen shoulders or adhesive capsulitis following a fracture WILL be funded as undertaking manipulation under anaesthetic increases the risk of a re-fracture.

Rationale

Rationale for shoulder arthroscopy includes adhesive capsulitis, rotator cuff damage and recurrent instability. In these cases, the evidence supports the use of shoulder arthroscopy for treatment purposes. However, the use of arthroscopy for diagnostic purposes is not supported and radiological investigations should be used for this.

In most circumstances, a clinical examination (history and examination) by a competent clinician will give a diagnosis and demonstrate if internal joint derangement is present. If there is diagnostic uncertainty despite competent examination or if there are "red flag” symptoms/signs/conditions, then an MRI scan might be indicated.

References

1. Coghlan JA, Buchbinder R, Green S, Johnston RV, Bell SN, Surgery for rotator cuff
disease, Cochrane Database of Systematic Reviews 2008, Issue 1. Art. No.: CD005619.
DOI: 10.1002/14651858.CD005619.pub2
2. NICE CKS revised April 2015 accessed online via https://cks.nice.org.uk/shoulder-pain
3. Woo Hyung Lee et al, Clinical Outcomes of Conservative Treatment and Arthroscopic
Repair of Rotator Cuff Tears: A Retrospective Observational Study, Ann Rehabil Med
2016;40(2):252-262 pISSN: 2234-0645 eISSN: 2234-0653 http://dx.doi.org/10.5535/arm.2016.40.2.252 
4. Baums et. al. Functional outcome and general health status in patients after arthroscopic
release in adhesive capsulitis. Knee Surg Sports Traumatol Arthrosc. 2007 May; 15(5):638-
44.
5. Snow M, Boutros I, Funk L. Posterior arthroscopic capsular release in frozen shoulder.
Arthroscopy. 2009 Jan; 25(1):19-23.
6. Fernandes MR. Arthroscopic treatment of adhesive capsulitis of the shoulder with
minimum follow up of six years. Acta Ortop Bras. 2015 Mar-Apr; 23(2): 85–89. doi:
1590/1413- 78522015230200613 PMCID: PMC4813413
7. Wei Dong et. al. Treatments for Shoulder Impingement Syndrome. A PRISMA Systematic
Review and Network Meta-Analysis, Medicine, Volume 94, Number 10, March 2015.
8. Bhatnagar A1, Bhonsle S2, Mehta S1. Correlation between MRI and Arthroscopy in
Diagnosis of Shoulder Pathology. J Clin Diagn Res. 2016 Feb; 10(2):RC18-21
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4800609/ 
9. Frozen Shoulder - Amar Rangan, Lorna Goodchild, Jo Gibson, Peter Brownson, Michael
Thomas, Jonathan Rees, and Ro Kulkarni https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4935124/10.http://www.isrctn.com/ISRCTN48
804508  
10. Beard JD et al. Arthroscopic subacromial decompression for subacromial shoulder pain
(CSAW): a multicentre, pragmatic, parallel group, placebo-controlled, three-group,
randomised surgical trial. The Lancet November 20, 2017 http://dx.doi.org/10.1016/S0140-6736(17)32457-1

Back