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Lessons to be learnt from the study ‘Sham surgery versus labral repair or biceps tenodesis for type II SLAP lesions of the shoulder: a three-armed randomised clinical trial’
  1. Ann M Cools,
  2. Dorien Borms
  1. Department of Rehabilitation Sciences and Physiotherapy, Ghent University, Gent, Belgium
  1. Correspondence to Professor Ann M Cools, Ghent University, Rehabilitation Sciences and Physiotherapy, Gent, 9000, Belgium; ann.cools{at}

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‘Real surgery is no better than sham surgery in isolated type II SLAP lesions’. That is the first interpretation the reader may make based on the study published by Schröder et al in BJSM. 1 First, let us congratulate the authors for conducting such a well-designed study on a large sample of patients, with a research question that is extremely relevant to patients and to payers.

Superior labral tear from anterior to posterior(SLAP) lesions have been much written about and likely been overdiagnosed and overtreated.2 Numerous papers presented new diagnostic tests3 and postoperative outcome after SLAP repairs,4 and a few studies explored the benefit of conservative, non-operative treatment.5–7

Sham surgery proves as successful as real surgery

Schröder and colleagues show that surgery consisting of labral repair or biceps tenodesis provides no benefit over sham surgery for isolated type II SLAP lesions. Although the study was not large enough to stratify patients into subgroups based on physical (sports) activity level and age, which may predict successful outcome after surgery, the study should influence clinical decision making relating to biceps tendon and superior labrum injuries considerably.

How does sham surgery ‘work’? Or is there power in targeted rehabilitation exercises?

The study begs the question: Which factors determine the success of sham surgery and/or conservative treatment? Is it because in this study the ‘sham’ procedure still included an arthroscopy, without any structures being repaired? The only way to be certain would be to compare this with another form of sham procedure where only skin incisions were made and an arthroscopic evaluation was not undertaken.

Is the patient’s perception of having undergone a surgical intervention critical to success? Seventy-three percent of the patients in the sham surgery group believed they were repaired. Are psychological or emotional factors the key to success after surgery? Is the communication with the patient about the expected improvement after treatment important for the patient’s perception of the outcome?

Are the results in the ‘sham surgery’ group based on a well-designed rehabilitation programme, rather than natural healing and spontaneous recovery? The authors state that, although physiotherapy might have contributed to the results in all groups, the impact of placebo and the natural course should not be underestimated. Besides an arthroscopy, an intervention itself, the main intervention in the ‘sham surgery’ group (and all groups) was a physiotherapy programme.

The study design does not allow us to conclude as to the role of spontaneous recovery versus a rehabilitation programme. Given that the participants were selected on the basis of long-standing complaints and dysfunction, ‘natural healing’ should not be overestimated. Let us highlight the importance of a good rehabilitation programme. All patients in the study received an individually adjusted rehabilitation programme, based on standardised guidelines. Benefits from a specific exercise programme over a general programme have been shown previously in patients with subacromial pain syndrome.8

We believe this study highlights the importance of an evidence-based rehabilitation programme for SLAP lesions and biceps-related pathology. With the exception of some general rehabilitation guidelines9 (that are mainly time-based), only a few shoulder studies offered an exercise programme that progressed patients from low to high biceps load.10 11 There is a need for a staged and comprehensive rehabilitation programme, specifically loading the biceps appropriately. In the early stages, the biceps should be protected, whereas progressive loading of the biceps is needed in the final stages to permit return to activity or sports. These customised rehabilitation programmes should be evaluated on their benefit in a study design in which the exercise programme is the target and not implemented only as an adjunct to (real or sham) surgery.

Another point for discussion is whether patients comply and adhere better with exercise when they have had surgery compared with when there has been no surgical intervention. That, however, is outside the scope of our editorial.

This paper also challenges future research projects in the area of sham surgery to investigate the question of the emotional and psychological response to surgery.12 In the mean time, the paper from Schröder et al will definitely increase the intensity of the vigorous debate surrounding surgery versus non-operative rehabilitation in the clinical practice. That alone means the authors can claim ‘mission accomplished’.



  • Competing interests None declared.

  • Provenance and peer review Commissioned; externally peer reviewed.

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