Do Patients With Shoulder Pain Exhaust Nonoperative Care Prior to Undergoing Subacromial Decompression Surgery? Results From a Large Retrospective Observational Study of US Service Members

Importance: Clinical practice guidelines recommend individuals with subacromial pain syndrome (SAPS) exhaust conservative care, with an emphasis on therapeutic exercise, prior to undergoing subacromial decompression (SAD) surgery. To date, there are no studies that describe the care individuals with SAPS receive prior to undergoing SAD in a large health care system. Objective: The objective of this study was to characterize care received by patients undergoing SAD in the year before surgery with a focus on shoulder exercise visits. Design: This was a retrospective, longitudinal database study. Setting: This study included records from the Military Health System. Participants: Participants were United States active-duty service members (n=5917). Exposure: This study included patients who underwent SAD in a military treatment facility between 2015 through 2019. Main Outcomes and Measures: Medical imaging, shoulder injections, medications, and rehabilitation encounters were categorized using Current Procedural Terminology codes. Rehabilitation encounters were further categorized as exercise, manual therapy, and/or passive therapy visits. A multivariable negative binomial regression model was performed to identify factors associated with the number of exercise visits attended in the year preceding surgery. Results: Overall, 2171 (36.7%) service members did not attend any exercise visits in the year before surgery. Significant predictors of attending more exercise visits included undergoing at least 1 magnetic resonance imaging study, receiving a shoulder injection, and younger age (<25 years). Most patients (94.6%) underwent at least 1 shoulder-related imaging procedure. The most common therapeutic class of medication prescribed was nonsteroidal anti-inflammatory drugs (NSAIDs; 81.0%), followed by muscle relaxers (29.3%), opioids (27.3%), and analgesics that were not NSAIDs (24.4%). Conclusions: Therapeutic exercise was underutilized in our cohort, which may contribute to the overutilization of SAD in individuals with SAPS. Before considering SAD, providers should ensure patients with SAPS complete a course of evidence-based nonoperative care, to include supervised therapeutic exercise. Relevance: Increasing awareness of care patterns prior to SAD may help improve care pathways for individuals with SAPS.