CSAW was a UK multicentre, placebo-controlled randomised trial testing whether arthroscopic subacromial decompression actually works. It compared decompression, placebo arthroscopy (no bone or soft tissue removal), and no treatment for chronic subacromial pain with intact rotator cuffs. The primary outcome was the Oxford Shoulder Score at 6 months.
When a patient with chronic subacromial pain and an intact cuff has already failed exercise therapy and a steroid injection, CSAW says decompression is unlikely to help beyond what a sham operation delivers.
The trial's elegance is the placebo arm. Because decompression and diagnostic-only arthroscopy gave identical results, the mechanical impingement theory that justifies removing the spur does not hold up. The small edge of surgery over no treatment is best explained by placebo effect and postoperative physiotherapy, not by anything the scalpel did to the acromion.
For the ROCK rotator cuff rehabilitation objectives, the takeaway is that structured non-operative care deserves priority, and the postoperative physio package may be doing much of the work attributed to surgery. This is the first placebo-controlled trial of shoulder surgery and a direct counseling tool: share these findings during shared decision-making before offering decompression.
CSAW was a UK multicentre, placebo-controlled randomised trial testing whether arthroscopic subacromial decompression actually works. It compared decompression, placebo arthroscopy (no bone or soft tissue removal), and no treatment for chronic subacromial pain with intact rotator cuffs. The primary outcome was the Oxford Shoulder Score at 6 months.
When a patient with chronic subacromial pain and an intact cuff has already failed exercise therapy and a steroid injection, CSAW says decompression is unlikely to help beyond what a sham operation delivers.
The trial's elegance is the placebo arm. Because decompression and diagnostic-only arthroscopy gave identical results, the mechanical impingement theory that justifies removing the spur does not hold up. The small edge of surgery over no treatment is best explained by placebo effect and postoperative physiotherapy, not by anything the scalpel did to the acromion.
For the ROCK rotator cuff rehabilitation objectives, the takeaway is that structured non-operative care deserves priority, and the postoperative physio package may be doing much of the work attributed to surgery. This is the first placebo-controlled trial of shoulder surgery and a direct counseling tool: share these findings during shared decision-making before offering decompression.