Update of guideline for diagnosis and treatment of subacromial pain syndrome: a multidisciplinary review by the Dutch Orthopedic Association Part 2: Operative considerations and treatment of various conditions related to subacromial pain syndrome

Background and purpose: In 2013, the first clinical practice guideline for subacromial pain syndrome (SAPS) was developed in the Netherlands to support healthcare professionals. SAPS refers to non-traumatic, non-rheumatologic shoulder complaints that are particularly painful during arm elevation. It includes conditions such as supraspinatus tendinosis, calcific tendinitis, and degenerative supraspinatus tears. Over 50,000 patients annually consult orthopedic surgeons for these issues. In response to new evidence and clinical needs, an updated guideline was developed. Part 2 focuses on supraspinatus tears, biceps tendon pathology, and calcific tendinosis. Using a multidisciplinary, evidence-based approach, the guideline aims to answer key clinical questions around SAPS. Methods: Initiated by the Dutch Orthopedic Society, the guideline committee identified knowledge gaps through group sessions. Each module was based on a PICO-formatted key question and reviewed by professionals from different fields. The AGREE and GRADE methods were applied to ensure a systematic evaluation of evidence, leading to conclusions and recommendations. Results: (i) Start with exercise-based therapy (with corticosteroid injection) for isolated, symptomatic, non-traumatic supraspinatus tears. Consider cuff repair if no improvement after 3-6 months. (ii) Avoid biceps tenotomy/tenodesis on a healthy tendon unless at risk during cuff repair. (iii) Evaluate patient- and tear-specific factors; use MRI for detailed assessment. (iv) Consider barbotage for calcific tendinosis; repeat once if needed. Reserve surgery for persistent large calcifications. (v) Postoperative immobilization should not exceed 3 weeks. Conclusion: The updated guideline provides multidisciplinary recommendations for surgical management.