Shoulder Injections - The Evidence

L Funk, 2003

The shoulder has been traditionally known as the unanswered joint, with the main treatment of shoulder pain being corticosteroid injections and physiotherapy. With mounting evidence over the deleterious effects of corticosteroids on tendons and the arrival of Hyaluronan injections, we examine the evidence for the use of corticosteroid injections in the shoulder.

Benefits of Corticosteroid Injections

The Cochrane review [1] of the efficacy of corticosteroid injections for shoulder pain was updated in November 2002. Twenty-six Randomised and pseudo-randomised trials in all languages assessing the efficacy of corticosteroid injections were reviewed. These included trials comparing corticosteroids to placebo or another intervention, and of varying types and dosages of steroid injection in adults with shoulder pain. Specific exclusions were duration of shoulder pain less than three weeks, rheumatoid arthritis, polymyalgia rheumatica and fracture. For rotator cuff disease, subacromial steroid injection was demonstrated to have a small benefit over placebo in some trials however no benefit of subacromial steroid injection over NSAID was demonstrated.

They concluded that there is little overall evidence to guide treatment and subacromial corticosteroid injections for rotator cuff disease may be beneficial, although their effect may be small and not well-maintained.

Adverse Effects of Corticosteroid Injections

The accuracy of injecting corticosteroid into the subacromial bursa is at best 70% in the hands of an experienced shoulder surgeon [6,7]. Thus in 30% of cases corticosteroid is being injected into the surrounding tissues including the rotator cuff tendon and muscle.

Nelson et al. reviewed the use of corticosteroid injections in primary care [11]. They noted the local complications of corticosteroid injection include tendon and ligament weakening, bacterial infections of joints and related structures, and subcutaneous tissue atrophy. Systemic complications were rare but included hyperglycemia and adrenal axis suppression.

A number of studies have expressed concerns that steroids injected into the tendons and muscles can significantly weaken the collagen fibres and precipitate rotator cuff ruptures when injected for subacromial impingement[2-5]. Corticosteroids damage the ultrastructure of collagen molecules, reduce collagen density [8], as well as inhibiting the reparative properties of tendon by inhibiting tendon cell migration [9] and synovial fibroblast proliferation [10].

Due to the clinical complications of steroid injections into tendons, Fredberg in 1997  stated that the injection of corticosteroid inside the tendon has a deleterious effect on the tendon tissue and should be unanimously condemned [12].

Corticosteroids injected into the subcutaneous tissues can cause lipodystrophy and soft tissue infections. This is more common following repeated injections and in immunocompromised and rheumatoid patients [3,8,14].

Due to the nature of rheumatoid arthritis and the disease process effects on tendons, repeated corticosteroid injections compound the tissue damaging effects and make any surgical repair of these tissues more difficult and more likely to fail [8,13,14].

Hyaluronans

Subacromial injection is an important part of the management of impingement syndrome, therefore are there safer substances to use instead of steroids?

Hyaluronan (HA) injections have been proven to be as effective as corticosteroids for the treatment of impingement syndrome and rotator cuff disease [8,15], without the complications associated with corticosteroids.

At present, we are prospectively comparing a Hyaluronan (Ostenil) with corticosteroid (Depomedrone) for impingement syndrome and selected cases of arthritis (unfit for surgery).

Our early experience is that Ostenil is as effective as corticosteroids with regard to pain relief and range of motion.

Also See:
- Hyaluronans - Basic Science
- Hyaluronans in the Shoulder

References

1. Buchbinder R, Green S, Youd JM. Corticosteroid injections for shoulder pain (Cochrane Review). In: The Cochrane Library, Issue 2 2003. Oxford: Update Software.

2. Tillander B, Franzen LE, Karlsson MH, Norlin R. Effect of steroid injection of the rotator cuff: An experimental study in rats. J Shoulder Elbow Surg. 1999;8:271-274.

3. Gottlieb NL, Riskin WG. Complications of local corticosteroid injections. JAMA. 1980;243:1457-1548.

4. Holmes GB, Mann RA. Possible epidemiological factors associated with rupture of the posterior tibial tendon. Foot Anke. 1992;13:70-79.

5. Kleinman M, Gross AE. Achilles tendon rupture following steroid injection:Report of three cases. J Bone Joint Surg Am. 1983;65:1345-1347.

6. Yamakado K. The targeting Accuracy of Subacromial Injection to the shoulder: an arthrographic evalustion. JArthroscopic & Related Surg. 2002;18(8):887-891.

7. Partington PF, Broome GH. Diagnostic injection around the shoulder. Hit and miss? A cadaveric study of injection accuracy. J Shoulder Elbow Surg. 1998;7:147-150.

8. Shibata et al. Presented at the AAOS, Anaheim, Ca. Feb 1999. Press release from the Academy News Newsletter. 05/02/1999. "Hyaluronate Sodium Eases Pain of Rotator Cuff Tear."

9. Wen-Chung tsai, Fuk-Tan Tang, May-Kuen Wong, Jong-Hwei S Pang. Inhibition of tendon cell migration by dexamethasone is correlated with reduced alpha-smooth muscle actin gene expression: a potential mechanism of delayed tendon healing. J Orth Res. 2003;21:265-271.

10.  Hamilton JH, Bootes A, Phillips PE, Slywka J. Human synovial fibroblast plasminogen activator. Modulation of enzyme activity by anti-inflammatory steroids. Arthritis Rheum. 1981;24:1296-1303.

11. Nelson, K. H., W. Briner, Jr., et al. (1995). "Corticosteroid injection therapy for overuse injuries." Am Fam Physician 52(6): 1811-6.

12. Fredberg, U. (1997). "Local corticosteroid injection in sport: review of literature and guidelines for treatment." Scand J Med Sci Sports 7(3): 131-9.

13. Lauzon, C., S. Carette, et al. (1987). "Multiple tendon rupture at unusual sites in rheumatoid arthritis." J Rheumatol 14(2): 369-71.

14. Hiemstra LA, MacDonald PB, Froese W. Subacromial infection following corticosteroid injection. J Shoulder Elbow Surg. 2003;12:91-93.

15. Raynauld JP, Choquette D, Haraoui B, Zummer M, Pelletier JP. Hylan versus triamcinolone acetonide injection for acute supraspinatus tendinitis: Early report of a randomised controlled trial. Arthritis Rheum. 1994;37(Supp9):1111.

Title: Local corticosteroid injection in sport: review of literature and guidelines for treatment.
Author: Fredberg U
Address: AGF Professional Soccer A/S, Aarhus, Denmark.
Source: Scand J Med Sci Sports, 7(3):131-9 1997 Jun

Abstract:
The risks and benefits of local injection therapy of overuse sports injuries with corticosteroids are reviewed here. Injection of corticosteroid inside the tendon has a deleterious effect on the tendon tissue and should be unanimously condemned. No reliable proof exists of the deleterious effects of peritendinous injections. Too many conclusions in the literature are based on poor scientific evidence and it is just the reiteration of a dogma if all steroid injections are abandoned. The corticosteroids represent an adjuvant treatment in the overall management of sports injuries: basic treatment is 'active' rest and graduated rehabilitation within the limits of pain. With proper indications there are only few and trivial complications that may occur with corticosteroid injections. Guidelines for proper local injection therapy with corticosteroids are given.

Title: Joint and soft-tissue injection. A useful adjuvant to systemic and local treatment.
Author: Genovese MC
Address: Division of Immunology and Rheumatology, Stanford University Medical Center, Stanford, CA 94305, USA.
Source: Postgrad Med, 103(2):125-34 1998 Feb

Abstract:
Joint and soft-tissue injection can augment systemic and local conservative treatment and have long-lasting benefits. Inflammatory and crystalline arthritis, synovitis, tendinitis, bursitis, and many other conditions respond well to injection. Corticosteroid preparations should be chosen on the basis of solubility and potency desired and the size of structure to be injected. Injections should not be made directly into a ligament or tendon and should be limited to every third or fourth month. With attention to the usual cautions required with corticosteroid use and avoidance of contraindications (e.g., bacteremia, fracture), injection is usually safe and effective, particularly as a bridging technique to long-term therapy.

Title: Local corticosteroid injection in sport: review of literature and guidelines for treatment.
Author: Fredberg U
Address: AGF Professional Soccer A/S, Aarhus, Denmark.
Source: Scand J Med Sci Sports, 7(3):131-9 1997 Jun

Abstract:
The risks and benefits of local injection therapy of overuse sports injuries with corticosteroids are reviewed here. Injection of corticosteroid inside the tendon has a deleterious effect on the tendon tissue and should be unanimously condemned. No reliable proof exists of the deleterious effects of peritendinous injections. Too many conclusions in the literature are based on poor scientific evidence and it is just the reiteration of a dogma if all steroid injections are abandoned. The corticosteroids represent an adjuvant treatment in the overall management of sports injuries: basic treatment is 'active' rest and graduated rehabilitation within the limits of pain. With proper indications there are only few and trivial complications that may occur with corticosteroid injections. Guidelines for proper local injection therapy with corticosteroids are given.

© Lennard Funk 2003