Joint Injection Substances
Shoulder Injections - The Evidence
L Funk, 2005
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  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 . 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 , as well as inhibiting the reparative properties of tendon by inhibiting tendon cell migration  and synovial fibroblast proliferation .
A recent meta-analysis of the published literature  on corticosteroids in athletes found that the most common complication related to steroid injections was tendon and fascial rupture.
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 .
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].
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.
Our early experience is that Hyaluronans (Ostenil) are as effective as corticosteroids with regard to pain relief and range of motion, but without the complications [17,18].
Unlike corticosteroids, Hyaluronans are also not restricted by the World Anti-doping Authority.
- Hyaluronans - Basic Science
- Hyaluronans in the Shoulder
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.
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.
© Lennard Funk 2005