Effect of steroid injections on the rotator cuff: an experimental study in rats

Corticosteroid injection of the knee within one month prior to meniscus repair increases the risk of repair failure requiring meniscectomy

OBJECTIVE

Meniscal tears are common knee injuries with limited endogenous healing capacity. This study aimed to investigate the association between the timing and administration of preoperative intra-articular corticosteroid injections (CSIs) and the risk of subsequent meniscectomy following meniscus repair.

METHODS

Using a national insurance claims database, patients aged 18-40 years undergoing meniscus repair within six months of tear diagnosis were studied. Patients were categorized based on whether they received preoperative CSIs within three intervals prior to repair. Multivariable logistic regression was used to analyze the risk of follow-up meniscectomy while controlling for various patient-related variables.

RESULTS

Among 5,390 patients meeting inclusion criteria, 201 received preoperative CSIs. The CSI group was older and had higher rates of diabetes, obesity, and knee osteoarthritis. The overall rate of follow-up meniscectomy did not differ between groups. However, CSIs performed within one month prior to repair were associated with significantly higher odds of subsequent meniscectomy compared to CSIs performed between three and six months prior. Obesity, tobacco use, and knee osteoarthritis were also independently associated with higher risk, while increasing age was associated with lower risk.

CONCLUSION

The study highlights an increased risk of repair failure requiring follow-up meniscectomy for patients receiving intra-articular CSIs within one month prior to meniscus repair. These findings suggest caution when considering CSIs as a treatment option for patients scheduled for meniscus repair. Further research is needed to establish optimal timing guidelines for CSIs in relation to meniscus repair and to understand the underlying mechanisms.

A Systematic Review and Meta-analysis of Risk Factors for the Increased Incidence of Revision Surgery After Arthroscopic Rotator Cuff Repair

BACKGROUND

Approximately 90% of patients who undergo arthroscopic rotator cuff repair (RCR) are satisfied with their pain levels and function after surgery. However, a subset of patients experience continued symptoms that warrant revision surgery. Preoperative risk factors for RCR failure requiring revision surgery have not been clearly defined.

PURPOSE

To (1) determine the rate of RCR failure requiring revision surgery and (2) identify risk factors for revision surgery, which will help surgeons to determine patients who are at the greatest risk for RCR failure.

STUDY DESIGN

Systematic review and meta-analysis; Level of evidence, 4.

METHODS

A systematic review and meta-analysis in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were performed. The initial search resulted in 3158 titles, and 533 full-text articles were assessed for eligibility. A total of 10 studies met the following inclusion criteria: (1) human clinical studies, (2) arthroscopic RCR, (3) original clinical research, and (4) evaluation of preoperative risk factors for revision.

RESULTS

After a full-text review, a total of 16 risk factors were recorded and analyzed across 10 studies. Corticosteroid injection was the most consistent risk factor for revision surgery, reaching statistical significance in 4 of 4 studies, followed by workers' compensation status (2/3 studies). Patients with corticosteroid injections had a pooled increased risk of revision surgery by 47% (odds ratio, 1.44 [95% CI, 1.36-1.52]). Patients with workers' compensation had a pooled increased risk of revision surgery by 133% (odds ratio, 2.33 [95% CI, 2.09-2.60]). Age, smoking status, diabetes, and obesity were found to be risk factors in half of the analyzed studies.

CONCLUSION

Corticosteroid injections, regardless of the frequency of injections, and workers' compensation status were found to be significant risk factors across the literature based on qualitative analysis and pooled analysis. Surgeons should determine ideal candidates for arthroscopic RCR by accounting for corticosteroid injection history, regardless of the frequency, and insurance status of the patient.

Treatment of Calcific Tendonitis of the Rotator Cuff: An Updated Review

Rotator cuff calcific tendonitis (RCCT) is a disorder that can greatly impair patients' quality of life. A literature review was conducted to find the most effective and newest treatments for RCCT. PubMed and Cochrane Review databases were searched, without strict inclusion/exclusion criteria, for peer-reviewed articles between 1941 and 2021 that discussed RCCT etiology and treatments. If nonoperative measures (non-steroidal anti-inflammatory drugs, physical therapy, and corticosteroids) are unsuccessful, other options include extracorporeal shockwave therapy, ultrasound-guided injection techniques, and minimally invasive surgery. Because RCCT can resolve spontaneously, patients should progress to invasive options only if conservative first-line treatments have failed. [Orthopedics. 2023;46(6):e326-e332.].

Kalkschulter – konservative und operative Therapie

Erkrankungen der Rotatorenmanschette beinhalten ein breites Spektrum, unter denen die Kalkschulter oder Tendinosis calcarea (TC) eine häufige Pathologie der Schulter darstellt und eine herausragende Rolle einnimmt. Das Erscheinungsbild kann dabei enorm variieren. Die Kalkschulter kann als Zufallsbefund bei der radiologischen Diagnostik auffallen, jedoch auch bis hin zu einem der stärksten Schulterschmerzen avancieren. Nachfolgend wird ein Überblick für das diagnostische und therapeutische Vorgehen gegeben.

Effects of hyaluronic acid injections on pain and functioning in patients affected by tendinopathies: A narrative review

BACKGROUND

Tendinopathies are overuse tendon injuries showing load-dependant pain, stiffness, weakness of movement in the affected area, and impairment in the movements. The scientific interest on the role of Hyaluronic Acid (HA) for the management of tendinopathies has been increased due to its anti-inflammatory and lubricative properties.

OBJECTIVE

To collect evidence regarding the effectiveness and safety of HA injections in reducing pain in patients affected by tendinopathies.

METHODS

A scientific literature search was conducted using the PubMed, Medline and PEDro electronic databases. The databases were searched since their inception until July 2021. The search was limited to English language articles. Different combinations of the terms and MeSH terms "tendinopathy", "tendinosis", "tendinitis", "hyaluronic acid", "hyaluronate", "infiltration", "hyaluronic injections", "viscosupplementation" connected with various boolean operators were used for other electronic databases.

RESULTS

One hundred and one records were identified from the selected databases plus three additional papers identified by the authors through other sources. After removing duplicated papers and title/abstract screening, 19 studies were included in our review (eight papers on shoulder, three on elbow, four on hand, one on knee, and three on ankle).

CONCLUSION

The results showed that none of the studies report severe adverse effects and most of them support the use of HA injections in tendinopathies, with a special attention to pain reduction and functional assessment. Further studies are warranted to better investigate effects and methods of administration of HA in tendinopathies.

Comparison of single platelet-rich plasma injection with hyaluronic acid injection for partial-thickness rotator cuff tears

BACKGROUND

Partial-thickness rotator cuff tears (PTRCTs) is not uncommon, and various nonsurgical injection therapy for PTRCTs emerged. Platelet-rich plasma (PRP) and hyaluronic acid (HA) injection were proposed for treating PTRCTs; however, the relation of dose among injectates was still lacking.

METHODS

This was a prospective, nonrandomized, comparative study. The aim of the study was to compare the effects of ultrasound-guided single PRP injection with three doses of HA injection, combination of postinjection rehabilitation, for treating PTRCTs. Subjects received either ultrasound-guided PRP injection and rehabilitation exercise, or ultrasound-guided subacromial HA injection and rehabilitation exercise. Shoulder Pain and Disability Index (SPADI), range of motion (ROM), pain visual analog scale (VAS), and Constant-Murley Shoulder Score (CMSS) were recorded before injection, and at 1 and 3 months after injection.

RESULTS

Forty-eight patients were enrolled. They received either ultrasound-guided single PRP (n = 24) intralesional and peritendinous injection or three doses of HA (n = 24) subacromial injection plus rehabilitation exercise. In the PRP group, SPADI scores, VAS scores, CMSS significantly improved at 1-month and 3-month follow up; flexion and abduction ROM significantly increased at 3-month follow up. In the HA group, SPADI scores, VAS during overhead activities, VAS night pain, and CMSS significantly improved in the first and third months; flexion and active abduction ROM significantly increased in the third month. The PRP group revealed significantly better passive abduction ROM and CMSS at third month than HA group.

CONCLUSION

Ultrasound-guided single PRP injection exhibited comparable benefit to three doses of HA injection in patients with PTRCTs short-termly, with an extended effect regarding passive shoulder abduction ROM and CMSS.

Modulation of Inflammation by Plant-Derived Nutraceuticals in Tendinitis

Tendinitis (tendinopathy) is a pro-inflammatory and painful tendon disease commonly linked with mechanical overuse and associated injuries, drug abuse, and lifestyle factors (including poor diet and physical inactivity) that causes significant healthcare expenditures due to its high incidence. Nuclear factor kappa B (NF-κB) is one of the major pro-inflammatory transcription factors, along with other inflammation signaling pathways, triggered by a variety of stimuli, including cytokines, endotoxins, physical and chemical stressors, hypoxia, and other pro-inflammatory factors. Their activation is known to regulate the expression of a multitude of genes involved in inflammation, degradation, and cell death. The pathogenesis of tendinitis is still poorly understood, whereas efficient and sustainable treatment is missing. Targeting drug suppression of the key inflammatory regulators represents an effective strategy for tendinitis therapy, but requires a comprehensive understanding of their principles of action. Conventional monotherapies are often ineffective and associated with severe side effects in patients. Therefore, agents that modulate multiple cellular targets represent therapeutic treatment potential. Plant-derived nutraceuticals have been shown to act as multi-targeting agents against tendinitis via various anti-oxidant and anti-inflammatory mechanisms, whereat they were able to specifically modulate numerous signaling pathways, including NF-κB, p38/MAPK, JNK/STAT3, and PI3K/Akt, thus down-regulating inflammatory processes. This review discusses the utility of herbal nutraceuticals that have demonstrated safety and tolerability as anti-inflammatory agents for the prevention and treatment of tendinitis through the suppression of catabolic signaling pathways. Limitations associated with the use of nutraceuticals are also described.

The time of postoperative corticosteroid injection can be individualized after arthroscopic rotator cuff repair

BACKGROUND

Intra-articular corticosteroid injection is an effective treatment for pain and to improve the range of motion (ROM) of the shoulder joint. However, consideration of when it would be effective to inject corticosteroids after rotator cuff repair is more limited. The purpose of this study was to compare the outcomes of corticosteroids injection given at 4 and 8 weeks after arthroscopic rotator cuff repair.

METHODS

Between December 2016 and January 2018, 42 patients who underwent arthroscopic supraspinatus tendon repair were enrolled. Nineteen patients received 40 mg of triamcinolone injection 4 weeks after surgery (group 1), while 23 patients received the same injection 8 weeks after surgery (group 2). Clinical outcome was evaluated using ROM, American Shoulder and Elbow Surgeons (ASES) score, Constant score, Korean Shoulder score, and a visual analog scale (VAS) score before surgery and at 3, 6, and 12 months after surgery. Tendon integrity was assessed with magnetic resonance imaging (MRI) and sonography at 12 months after surgery.

RESULTS

Significant improvements in pain and functional scores were observed at the last follow-up in both groups (p < 0.05). There was no significant difference in VAS pain score between the two groups at any time point after surgery (p > 0.05). Functional scores and ROM in all directions also showed no statistical difference between the two groups (p > 0.05). Retears of the repaired tendon, assessed at 12 months postoperatively, were observed in two patients from group 1 (10.5%) and two patients from group 2 (8.7%), thus indicating no significant difference between the two groups (p > 0.05).

CONCLUSION

Since there was no significant difference in clinical outcomes and tendon integrity, postoperative corticosteroid injection can be individualized according to the patient for 4-8 weeks after the rotator cuff repair.

A Positive Correlation between Steroid Injections and Cuff Tendon Tears: A Cohort Study Using a Clinical Database

This cohort study aimed to investigate the association between steroid injections for shoulder diseases and the increased incidence of cuff tendon tears. The Kaohsiung Veterans General Hospital clinical database was used in this study. Patients were enrolled using the corresponding diagnostic codes for shoulder diseases. Patients who received steroid injections were included in the case group, and those without steroid injections were included in the control group. The outcome measure was the occurrence of cuff tendon tears during the study period. Adjusted hazard ratios for outcomes were calculated using Cox regression analysis adjusted for sex, age, and comorbidities. Of the 1025 patients with shoulder disease, 205 were in the case group and 820 were in the control group. The incidence of cuff tendon tears was 9.8% in patients who received steroid injections (p < 0.001). The adjusted hazard ratios for steroid injections, smoking, and chronic liver disease were 7.44 (p < 0.001), 2.40 (p = 0.046), 3.25 (p = 0.007), respectively. Steroid injections on the shoulder were associated with a raised risk of cuff tendon tears by 7.44 times compared to non-injection. The incidence of cuff tendon tears increased by 3.25 times with concurrent chronic liver disease and by 2.4 times with smoking.

Calebin A, a Compound of Turmeric, Down-Regulates Inflammation in Tenocytes by NF-κB/Scleraxis Signaling

Calebin A (CA) is one of the active constituents of turmeric and has anti-inflammatory and antioxidant effects. Excessive inflammation and cell apoptosis are the main causes of tendinitis and tendinopathies. However, the role of CA in tendinitis is still unclear and needs to be studied in detail. Tenocytes in monolayer or 3D-alginate cultures in the multicellular tendinitis microenvironment (fibroblast cells) with T-lymphocytes (TN-ME) or with TNF-α or TNF-β, were kept without treatment or treated with CA to study their range of actions in inflammation. We determined that CA blocked TNF-β-, similar to TNF-α-induced adhesiveness of T-lymphocytes to tenocytes. Moreover, immunofluorescence and immunoblotting showed that CA, similar to BMS-345541 (specific IKK-inhibitor), suppressed T-lymphocytes, or the TNF-α- or TNF-β-induced down-regulation of Collagen I, Tenomodulin, tenocyte-specific transcription factor (Scleraxis) and the up-regulation of NF-κB phosphorylation; thus, its translocation to the nucleus as well as various NF-κB-regulated proteins was implicated in inflammatory and degradative processes. Furthermore, CA significantly suppressed T-lymphocyte-induced signaling, similar to TNF-β-induced signaling, and NF-κB activation by inhibiting the phosphorylation and degradation of IκBα (an NF-κB inhibitor) and IκB-kinase activity. Finally, inflammatory TN-ME induced the functional linkage between NF-κB and Scleraxis, proposing that a synergistic interaction between the two transcription factors is required for the initiation of tendinitis, whereas CA strongly attenuated this linkage and subsequent inflammation. For the first time, we suggest that CA modulates TN-ME-promoted inflammation in tenocytes, at least in part, via NF-κB/Scleraxis signaling. Thus, CA seems to be a potential bioactive compound for the prevention and treatment of tendinitis.

The effects of a single-dose subacromial injection of a nonsteroidal anti-inflammatory drug in geriatric patients with subacromial impingement syndrome: a randomized double-blind study

Background

As nonsteroidal anti-inflammatory drugs (NSAIDs) and steroids have similar effects, steroids can be avoided to reduce adverse effects. This study aimed to compare the differences in symptom improvement after subacromial injection of steroids or NSAIDs.

Methods

Sixty patients with rotator cuff syndrome for at least 3 months were enrolled and divided into steroid and NSAID groups. The steroid group received a mixture of 1 mL of triamcinolone acetonide (40 mg/mL) and 1 mL of lidocaine hydrochloride 2%, while the NSAID group received a mixture of 1 mL of Ketorolac Tromethamine (30 mg/mL) and 1 mL of lidocaine hydrochloride 2%. The patients were assessed before and at 3, 6, and 12 weeks after the procedure. Shoulder scores from visual analog scale (VAS), American Shoulder and Elbow Surgeons (ASES), and University of California Los Angeles (UCLA) were used for evaluation.

Results

Both groups showed improvements in the clinical outcomes. Overall VAS, ASES, and UCLA scores improved from 6.9, 32.7, and 16.0 before the procedure to 2.0, 1.2, and 1.1; 81.5, 87.6, and 88.5; and 29.7, 31.8, and 32.0 at weeks 3, 6, and 12 weeks after the procedure, respectively. Twenty-six patients (86.7%) in the steroid group and 28 (93.3%) in the NSAID group reported satisfactory treatment outcomes. There were no significant differences in the outcomes between the two groups (p=0.671).

Conclusions

Subacromial injection of NSAIDs for rotator cuff tendinitis with shoulder pain had equivalent outcomes with those of steroid injection at the 12-week follow-up.

The Efficacy of Injections for Partial Rotator Cuff Tears: A Systematic Review

(1) Background: Even though rotator cuff tears are the most frequent tendon injuries in adults, the effectiveness of conservatively treated partial-thickness tears still remains a matter of debate. The purpose of this review is to compare corticosteroid injections to other drugs in the treatment of partial rotator cuff tears, focusing on the effectiveness of this therapeutic modality in terms of pain and shoulder functionality. (2) Methods: A systematic electronic search was performed using the PubMed (MEDLINE), EMBASE and Cochrane Library databases. All studies comparing the use of corticosteroids and other infiltrative techniques in the treatment of partial lesions (excluding studies that considered subacromial impingement as inclusion criteria) were pooled, data were extracted and statistically analyzed. (3) Results: Nine studies were included in this systematic review. Those studies, composed by a total of 494 shoulders treated, have been published from 1985 to 2019. All compared techniques have shown a significant improvement over baseline condition. PRP (Platelet Rich Plasma) injections have been shown to be significantly more effective in both functional and pain control only in the long term. (4) Conclusions: None of the techniques prevail indisputably on the others. Anyway, the treatment of partial rotator cuff tears with PRP injections seems to lead to significantly better outcomes in terms of pain and shoulder function in long term follow up. Whereas in short and medium term follow up, PRP injections was superior only in terms of shoulder function. The small number of studies on prolotherapy did not enable us to provide an opinion on the outcomes of this technique.

Isolated calcific tendinitis at the posterosuperior labrum: a rare case study

Calcific tendinitis of the shoulder joint, also known as chemical furuncle of the shoulder, causes intense shoulder pain and usually occurs within 1-2 cm from the insertion of the rotator cuff. We experienced a rare case of calcific tendinitis in the posterosuperior labrum of the shoulder joint in a 39-year-old male patient who presented with severe pain and weakness in the right shoulder. Radiographs and magnetic resonance imaging (MRI) findings showed calcific tendinitis in the posterosuperior labrum of the shoulder joint. A 1-week attempt at conservative treatment failed, so the calcified deposit in the posterosuperior labrum was arthroscopically removed. The patient's symptoms were completely relieved, and satisfactory clinical outcomes were achieved. Postoperative follow-up X-ray and MRI showed no recurrence of calcific tendinitis.

Effectiveness and safety of fluoroscopy-guided acupuncture for subacromial impingement syndrome: A randomized, patient-assessor blind, parallel clinical trial

Background

Subacromial impingement syndrome (SIS) is one of the most common causes of shoulder pain, and acupuncture treatment is widely used as treatment. However, no studies have examined image-guided acupuncture for SIS. This study evaluated the effectiveness and safety of low-dose X-ray guided acupuncture (LA) in patients with SIS.

Methods

A total of 54 patients with SIS were randomly allocated to the LA group and the conventional acupuncture (CA) group. Two acupuncture treatment sessions were conducted for a week, and follow up was conducted after three weeks. The primary outcome was pain intensity measured by the visual analogue scale (VAS) during the Neer and Hawkins test. The incidence rate of shoulder impingement sign, the modified Constant-Murley score (CMS) and the Shoulder Pain and Disability Index (SPADI) were assessed as other outcomes. All indicators were assessed at baseline and after one week and three weeks. For safety evaluation, adverse events were monitored in both groups.

Results

The change in pain during the Neer test after one week from baseline was more significant in the LA group than in the CA group (p=0.008). However, the Hawkins test did not show a difference between the two groups. The incidence rate of shoulder impingement sign and the changes in CMS and SPADI were not significantly different between the two groups at one week, but after three weeks, SPADI was more significantly improved in the LA group (p=0.024). No adverse events were related to this trial.

Conclusion

LA was more effective than CA in relieving pain and improving function in terms of VAS and SPADI.

Trial registration

This study was registered on 23 March 2018 at the Clinical Research Information Service: KCT0002751.

How periarticular corticosteroid injections impact the integrity of arthroscopic rotator cuff repair

INTRODUCTION

Multimodal analgesic (MMA) injections combined with corticosteroids have recently been shown to be effective for managing pain after arthroscopic rotator cuff repair.

HYPOTHESIS

The goal of this study was to analyze the effects of corticosteroid injections on the integrity of tendon repairs using magnetic resonance imaging (MRI). The hypothesis was that MMA injections combined with corticosteroids have no deleterious effects on functional outcomes and tendon healing 1 year after surgical rotator cuff repair.

METHODS

This was a prospective, double-blind study of 50 patients undergoing arthroscopic rotator cuff repair who were randomized into two groups. The study group (n=25) received a periarticular injection of a mixture of ropivacaine, morphine and methylprednisolone at the end of the procedure. The control group (n=25) received a placebo injection. The clinical outcomes were the pain level and complications, while the functional outcomes consisted of the Constant-Murley Score (CMS), American Shoulder and Elbow Surgeons Shoulder (ASES) score and Simple Shoulder Test (SST). The structural integrity of the operated tendons was analyzed on MRI at a mean follow-up of 15.1±1.3 months for the study group and 15.2±1.1 for the control group (p=0.848).

RESULTS

Pain on a visual analog scale was significantly reduced in both groups after the surgery. Nevertheless, there was no significant difference between groups at the final follow-up visit (p=0.803). Compared to the preoperative values, the CMS, ASES and SST significantly improved in both groups after surgery but were not significantly different between groups at the final assessment (p=0.801, 0.869 and 0.769, respectively). MRI revealed supraspinatus tendon retears in 16% of patients in the study group and 36% in the control group (p=0.107). There were no infections in the study group as of the final assessment. Advanced age (p=0.049), diabetes (p<0.01) and posterior extension of the tear (p=0.039) negatively impact healing. Corticosteroid injection did not negatively impact healing (p=0.197).

CONCLUSION

This study shows that MMA injection combined with corticosteroids does not alter the tendon healing, clinical outcomes, or functional outcomes 1 year after arthroscopic rotator cuff repair. It remains a safe and effective analgesia method during rotator cuff repair surgery.

LEVEL OF EVIDENCE

II, low-powered placebo-controlled, randomized study.

Corticosteroid Injections May Increase Retear and Revision Rates of Rotator Cuff Repair: A Systematic Review

PURPOSE

To synthesize the clinical outcome data of preoperative and postoperative corticosteroid injections (CIs) and their effect on rotator cuff repairs (RCRs).

METHODS

A systematic review was performed to identify studies that reported the results or clinical outcomes of RCRs in patients receiving either preoperative or postoperative CIs. The searches were performed using MEDLINE, Google Scholar, and Embase, and studies were chosen following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines.

RESULTS

A total of 11 studies were included with data for 176,352 shoulders: 6 studies involving 175,256 shoulders with data regarding preoperative CIs, 4 studies involving 1,096 shoulders with data regarding postoperative CIs, and 1 study with 212 shoulders containing preoperative and postoperative data. Preoperative CIs were found in 3 studies to increase the risk of revision surgery when administered within 6 months (odds ratio [OR], 1.38-1.82) and up to 1 year (OR, 1.12-1.52) prior to RCR, with revision rates in 2 studies being highest when patients received 2 or more injections (OR, 2.12-3.26) in the prior year. Postoperative CIs reduced pain and improved functional outcomes in 5 studies without increasing the retear rates (5.7%-19% for CI and 14%-18.4% for control) in most studies.

CONCLUSIONS

CIs provide benefit by relieving pain and improving functional outcome scores. However, repeated preoperative CIs may increase retear rates and the likelihood of revision surgery. A lower frequency of CI and longer preoperative waiting period after CI should be considered to decrease such risks. Postoperative CIs several weeks after RCR do not appear to increase retear rates.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I through IV studies.

Trans-coracoacromial Ligament Glenohumeral Injection With Arthroscopic Confirmation

PURPOSE

To arthroscopically evaluate the trans-coracoacromial ligament glenohumeral (GH) injection technique by understanding intra-articular needle-tip placement and potential misplacement and complications.

METHODS

The technique relies on the palpation of 3 bony landmarks: anterolateral corner of the acromion, superolateral border of the coracoid tip, and curved depression of the distal clavicle. The skin entry site lies on the line connecting the curved depression of the distal clavicle and superolateral border of the coracoid tip, two-thirds of the way from the former and one-third of the way from the latter. The direction of the needle is perpendicular to the triangle formed by the 3 bony landmarks. The technique is used to insufflate the GH joint at the start of shoulder arthroscopy procedures with patients in the beach-chair position. Saline solution is injected, and the position of the needle tip in the GH joint is evaluated arthroscopically. An injection is considered successful if saline solution can be injected and the needle tip can be visualized intra-articularly.

RESULTS

This study enrolled 195 patients undergoing shoulder arthroscopy. Successful needle placement in the GH joint occurred in 179 patients (91.8%); placement occurred through the rotator interval in 122 of these, adjacent or through the long head of the biceps tendon in 41, through the upper subscapularis or anterior supraspinatus in 13, and through the anterior labrum in 3. Regarding the 16 failures (8.2%), the needle position did not allow saline solution to be injected because of high resistance in 3 patients whereas the needle tip was not visualized in 13. The needle tip was presumed to rest within the subscapularis muscle or tendon or the labrum in 10 failed injections.

CONCLUSIONS

The trans-coracoacromial ligament injection technique showed a high success rate (91.8%) in anesthetized patients about to undergo arthroscopy, whereas the failed injections mainly occurred because the needle was inserted into the subscapularis or labrum. This technique can be used for awake patients with different diagnoses in multiple settings.

LEVEL OF EVIDENCE

Level IV, diagnostic study.

Nonbiologic Injections in Sports Medicine

Nonbiologic medications (local anesthetics, corticosteroids, and nonsteroidal anti-inflammatory drugs) are commonly administered to athletes for analgesia after injury. However, the risks of nonbiologic injections often are overlooked simply because of their long-term market availability. A thorough understanding of the mechanism of action, the reported benefits, and the potential risks of nonbiologic medications is crucial prior to their use, especially in the treatment of young athletes. Sports medicine physicians and surgeons must be aware of the systemic and local effects of these medications to ensure an appropriate drug choice that minimizes side effects and avoids recently reported toxicity to myocytes, tenocytes, and chondrocytes.

Intra-substance steroid injection for full-thickness supraspinatus tendon rupture

Background

The use of steroid injection for treatment of a full-thickness rotator cuff tear is still controversial. This study aimed to evaluate the effectiveness and safety of this treatment method.

Methods

Twelve patients in Group 1 received an intra-substance injection into rupture area of supraspinatus tendon with Diprospan 1 cc (betamethasone disodium phosphate 2 mg and betamethasone dipropionate 5 mg) and 1% xylocaine 1 cc. Twelve patients in Group 2 received an injection with normal saline 1 cc and 1% xylocaine 1 cc. The rupture size was measured by sonography before the injection, 3 months after the injection, and 6 months after the injection. Shoulder Pain and Disability Index (SPADI) score and Pain Visual Analogue Scale (VAS) score were measured and compared between the two groups before the injection, 1 week after the injection, 3 months after the injection, and 6 months after the injection.

Results

Pain and function improved more in Group 1 than in Group 2. The therapeutic effect lasted for at least 6 months in both groups. The size of the supraspinatus tendon rupture was not increased after injection in either group.

Conclusions

Intra-substance injection into rupture area of supraspinatus tendon with steroid and xylocaine is effective to reduce pain and improve function in patients with full-thickness supraspinatus tendon rupture without increasing the size of the rupture.

Trial registration

Current Controlled Trials ChiCTR1900026376, data of registration: 2019/10/05 retrospectively registered.

The Evaluation of Exogenous Melatonin Administration in Supraspinatus Overuse Tendinopathy in an Experimental Rat Model

Background

Increased oxidative stress and inflammation play a critical role in the etiopathogenesis of chronic tendinopathy. Melatonin is an endogenous molecule that exhibits antioxidant and anti-inflammatory activity. The aim of this study was to evaluate the biochemical and histopathological effects of exogenous melatonin administrations in supraspinatus overuse tendinopathy.

Methods

Fifty rats were divided into the following four groups: cage activity, melatonin treatment, corticosteriod therapy, and control. Melatonin (10 mg/kg, intraperitoneal; twice a day) and triamcinolone (0.3 mg/kg, subacromial; weekly) were administered to the treatment groups after the overuse period. Biochemical and histopathological evaluations were performed on serum samples and biopsies obtained from rats. Plasma inducible nitric oxide synthase (iNOS), vascular endothelial growth factor (VEGF), total antioxidant status (TAS), total oxidant status (TOS), and oxidative stress index (OSI) levels were evaluated biochemically.

Results

The TAS, TOS, OSI, iNOS, and VEGF values were significantly lower than the pre-treatment levels in rats receiving exogenous melatonin treatment (3 or 6 weeks) (p<0.05). TOS, iNOS, VEGF, and OSI values after 3 weeks of triamcinolone administration, and TOS, VEGF, and OSI levels after 6 weeks of triamcinolone application, were significantly lower than the pre-treatment levels (p<0.05).

Conclusions

Exogenous melatonin application in overuse tendinopathy reduces oxidative stress and inflammation. Melatonin might be an alternative potential molecule to corticosteroids in the treatment of chronic tendinopathy.

Is It Safe to Inject Corticosteroids Into the Glenohumeral Joint After Arthroscopic Rotator Cuff Repair?

BACKGROUND

Injection of intra-articular corticosteroids is effective for improving the recovery of range of motion (ROM) and pain in various conditions of the shoulder but its use is limited after rotator cuff repair owing to concern over the possible harmful effects of steroids on the repaired tendon.

PURPOSE

To evaluate the effect of intra-articular corticosteroid injections on the clinical outcomes and cuff integrity of patients after rotator cuff repair.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

Between March 2011 and April 2014, 80 patients with a small- to medium-sized rotator cuff tear were enrolled in this study and underwent arthroscopic rotator cuff repair. Forty patients received an injection of triamcinolone (40 mg) and lidocaine (1.5 mL) into the glenohumeral joint 8 weeks after surgery (group 1), while the remaining 40 patients received normal saline injection (group 2). Outcome measures-including ROM, American Shoulder and Elbow Surgeons (ASES) score, Constant score, pain visual analog scale, and Simple Shoulder Test score-were evaluated at 3, 6, and 12 months after surgery and at the last follow-up. The integrity of the repaired tendon was evaluated by magnetic resonance imaging (MRI) and classified per Sugaya classification at 8 weeks (before injection) and 12 months after surgery.

RESULTS

The mean follow-up period was 25.7 months. At 3 months postoperatively, patients in group 1 had a significantly higher ROM with respect to forward flexion ( P = .05), external rotation at the side ( P = .05), and external rotation at abduction ( P = .04) as compared with group 2, whereas no significant difference was noted between the groups for internal rotation behind the back ( P = .65). Patients in group 1 had significantly lower visual analog scale pain scores ( P = .02) and higher ASES scores (group 1, 68.90; group 2, 60.28; P = .02) at 3-month follow-up. However, there was no significant difference after 6 months with respect to ROM and ASES scores (group 1, 77.80; group 2, 75.88; P = .33). Retears (Sugaya classification IV and V) were determined by MRI at 12 months and observed in a total of 7 patients (8.8%): 3 from group 1 (7.5%) and 4 from group 2 (10%). No retears were observed on MRI in the remaining 73 patients (91.2%): 37 patients from group 1 and 36 patients from group 2. There was no statistically significant difference in rate of retears between groups ( P = .69).

CONCLUSION

Intra-articular injection of corticosteroids after rotator cuff repair does not increase the risk of retears and is thus an effective and safe treatment method for increasing ROM (forward flexion, external rotation) and improving clinical score (ASES) during the early postoperative period of patients undergoing rotator cuff repair.

Preoperative Shoulder Injections Are Associated With Increased Risk of Revision Rotator Cuff Repair

PURPOSE

The goal of this study was to determine whether the timing of preoperative shoulder injections is associated with an increased risk of revision rotator cuff repair following primary rotator cuff repair (RCR).

METHODS

A retrospective analysis of claims data of privately insured subjects from the MarketScan database for the years 2010 to 2014 was conducted. Multivariable logistic regression models were used to compare the odds of reoperation between groups. Laterality for the injection, index procedure, and subsequent surgery were verified for all subjects.

RESULTS

A total of 4,959 subjects with an arthroscopic RCR were identified, 392 of whom required revision RCR within the following 3 years. Patients who had an injection within 6 months preceding the index surgery were at a much higher risk of undergoing reoperation for revision RCR: 0 to 3 months prior, adjusted odds ratio (AOR) 1.375 (95% confidence interval [CI], 1.027-1.840); 3 to 6 months prior, AOR 1.822 (95% CI, 1.290-2.573); and 6 to 12 months prior, AOR 1.237 (95% CI, 0.787-1.943).

CONCLUSIONS

Patients who had received an injection within 6 months prior to RCR were much more likely to undergo a revision cuff repair within the following 3 years. The risk of reoperation significantly declines if there is more than 6 months between injection and RCR. Consideration should be given to minimizing preoperative injections in patients requiring RCR or delaying primary RCR for 6 months following injection.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Short-term Changes After Corticosteroid Injections Into the Normal Tendons of Rabbits: A Controlled Randomized Study

BACKGROUND

Corticosteroid injections in or around tendons for the treatment of athletic injuries are a common practice among orthopaedic surgeons and are apparently efficacious in the short term, although controversies persist related to local complications.

PURPOSE

This study evaluated short-term (48 hours) biomechanical, biochemical, and histological alterations after a single injection of betamethasone into the normal tendons of rabbits.

STUDY DESIGN

Controlled laboratory study.

METHODS

A total of 72 New Zealand White rabbits were randomly divided into 2 groups: the test group-in which 36 animals underwent 1 intratendinous injection of betamethasone (1.4 mg / 0.2 mL) in the right calcaneal tendon; the control group-in which the right calcaneal tendon of 36 animals was injected with saline (placebo control group) and the left calcaneal tendon was left untreated for normal standards (normal control). Forty-eight hours later, animals were euthanized and tendons were harvested. Metalloproteinase (MMP1 and MMP2) and interleukin (IL1 and IL6) expression levels, biomechanical resistance (load × elongation parameters), and histomorphometry (hematoxylin and eosin and picrosirius red stains for collagen fibers, tenocytes, and inflammatory cells) were analyzed in the tendons.

RESULTS

The test group had a significant reduction in MMP2 expression as compared with the control groups ( P = .027). Regarding the other parameters, there were no additional significant differences between the groups.

CONCLUSION

A single injection of corticosteroid into normal calcaneal tendons did not trigger acute local morphological, structural, or biomechanical injuries at 48 hours, but it did promote a significant decrease in MMP2 levels. Additional studies are needed with increased duration of follow-up, various doses, and multiple injections and in tendinopathic models.

CLINICAL RELEVANCE

Some previous studies demonstrated early structural changes in tendons after a single corticosteroid injection, which was not corroborated by the present study. Metalloproteinase decrease is usually associated with a reduction in collagen degradation, which would be protective for the healing process. More studies are necessary to confirm the possible beneficial effect of these results in the long term and for tendinopathies.

Preoperative Injections May Be an Iatrogenic Cause of Reoperation After Arthroscopic Rotator Cuff Repair

PURPOSE

To determine whether an association exists between preoperative shoulder injections and reoperations in patients undergoing arthroscopic rotator cuff repair (aRCR).

METHODS

The PearlDiver Patient Records Database was reviewed for Humana-insured patients undergoing aRCR after a shoulder injection. Two matched groups were created: aRCR within 1 year of injection (n = 12,054) and aRCR without prior injection within 1 year of surgery (n = 12,054). Reoperation rates within 3 months, at 3 to 6 months, and at 6 to 12 months postoperatively were assessed. Statistical analysis was performed with the χ-square test.

RESULTS

The rate of reoperation within 3 months of the index procedure was higher in the control group (3.7% vs 3.1%, P = .01); however, 3 to 6 months after the index procedure, the rate of reoperation was higher in patients who received an injection within 1 year of the index procedure (1.8% vs 1.4%, P = .03). During the same intervals, the rate of revision rotator cuff repair (RCR) within 3 months of the index procedure was higher in the control group (2.9% vs 2.6%) and the rate of revision RCR 3 to 6 months after the index procedure was higher in patients who received an injection within 1 year of the index procedure (1.1% vs 0.9%); however, these results were not statistically significant (P = .3 and P = .8, respectively). The incidence of revision RCR (1.6% vs 1.1%; odds ratio, 1.4; P = .003) and incidence of subacromial decompression (1.5% vs 1.1%; odds ratio, 1.3; P = .01) 6 to 12 months after the index procedure were significantly higher in patients receiving an injection within 1 year before surgery.

CONCLUSIONS

Preoperative shoulder injections may increase the risk of revision RCR and subacromial decompression by up to 150% in patients 6 to 12 months after index surgery compared with patients who did not receive a preoperative injection. However, the absolute increase in these revision procedures is only 0.5%.

LEVEL OF EVIDENCE

Level III, comparative study.

Increasing Numbers of Shoulder Corticosteroid Injections Within a Year Preoperatively May Be Associated With a Higher Rate of Subsequent Revision Rotator Cuff Surgery

PURPOSE

To identify any dose-dependent association between the use of subacromial corticosteroid injections within a year before rotator cuff repair (RCR) and subsequent need for revision rotator cuff surgery.

METHODS

Two large administrative databases were queried for patients undergoing arthroscopic RCR. A minimum of 1 year of preoperative database exposure and 2 years of postoperative database follow-up were required for inclusion. Patients were stratified into groups that received 0 (control), 1, 2, or 3 or more ipsilateral corticosteroid shoulder injections within the year prior to RCR. The outcome of interest was ipsilateral revision arthroscopic or open RCR or arthroscopic debridement for a diagnosis of rotator cuff tear within 2 years of the index surgery. Revision rates were compared between groups using a multivariate logistic regression analysis controlling for demographic and comorbidity confounders.

RESULTS

A total of 110,567 patients from the Medicare database and 12,892 patients from the private insurance database were included. There was no association between a single injection within the year prior to RCR and revision surgery in either cohort. The use of 2 or more injections was associated with a significant increase in the risk of requiring revision surgery in both the Medicare (odds ratio [OR], 2.76-3.26; P < .0001) and private insurance (OR, 2.53-2.87; P < .0001) populations.

CONCLUSIONS

A single shoulder injection within a year prior to arthroscopic RCR was not associated with any increased risk of revision surgery; however, the administration of 2 or more injections was associated with a substantially increased risk of subsequent revision rotator cuff surgery (OR, 2.53-3.26). Although causality cannot be established on the basis of this database review, caution is recommended when considering more than 1 shoulder corticosteroid injection in patients with potentially repairable rotator cuff tears.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Calcific tendinopathy of the shoulder: clinical perspectives into the mechanisms, pathogenesis, and treatment

Calcific tendinopathy (CT) of the shoulder is a common, painful condition characterized by the presence of calcium deposits in the rotator cuff tendons. Current theories indicate that CT may be the result of a cell-mediated process in which, after a stage of calcium deposition, calcifications are spontaneously resorbed. However, in a minority of cases, this self-healing process is somehow disrupted, resulting in symptoms. Recent literature shows an emerging role of biological and genetic factors underlying CT. This new evidence could supplement the classic mechanical theory of rotator cuff tendinopathy complicated by calcium precipitation, and it may also explain why the majority of the therapies currently in use are only able to provide partially satisfactory outcomes. This review aims to summarize the current knowledge about the pathological processes underlying CT of the shoulder and thereby justify the quest for advanced biological treatments of this condition when it becomes symptomatic.

An Intra-articular Steroid Injection at 6 Weeks Postoperatively for Shoulder Stiffness After Arthroscopic Rotator Cuff Repair Does Not Affect Repair Integrity

BACKGROUND

Shoulder stiffness is a common complication after arthroscopic rotator cuff repair. However, there is no consensus on the treatment of stiffness after repair. Although one treatment option is an intra-articular steroid injection, it may negatively affect repair integrity, and there is a paucity of literature regarding the timing of intra-articular injections for stiffness after repair and its effect on repair integrity.

PURPOSE

To compare repair integrity and clinical outcomes after an intra-articular steroid injection administered at 6 weeks and 12 weeks postoperatively for shoulder stiffness after arthroscopic rotator cuff repair.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients who developed stiffness after arthroscopic rotator cuff repair were given a series of 3 intra-articular steroid injections every 4 weeks from 6 (6-week group) and 12 weeks (12-week group) postoperatively. The control group had rotator cuff tears but neither stiffness nor injections. Shoulder range of motion (ROM), the Korean Shoulder Scoring System (KSS) score, and the University of California, Los Angeles (UCLA) shoulder score were assessed preoperatively with a minimum of 2-year follow-up. Repair integrity was assessed using magnetic resonance imaging at 6 months postoperatively.

RESULTS

Seventy-four of 209 patients (35.4%) who underwent arthroscopic rotator cuff repair developed stiffness. There were no significant differences in retear rates among the 6-week (5.7%, 2/35 patients), 12-week (10.3%, 4/39 patients), and control groups (14.1%, 19/135 patients) ( P = .374). Both the 6- and 12-week groups showed significant improvement in ROM (both P < .001), KSS scores (both P < .001), and UCLA scores (both P < .001) at the final follow-up. The 6-week group showed significantly better ROM ( P < .001), KSS scores ( P < .001), and UCLA scores ( P < .001) than the 12-week group at 3 months postoperatively. However, both the 6- and 12-week groups showed significantly lower KSS (81.3 ± 12.0 [ P = .004] and 83.4 ± 8.6 [ P = .035], respectively) and UCLA (29.3 ± 4.6 [ P = .006] and 30.0 ± 3.3 [ P = .042], respectively) scores than the control group (90.4 ± 13.6 and 32.3 ± 4.7, respectively) at the last follow-up.

CONCLUSION

An intra-articular steroid injection administered at 6 weeks postoperatively for shoulder stiffness after arthroscopic rotator cuff repair may be effective for reducing patients' pain and improving shoulder ROM at 3 months postoperatively without compromising repair integrity.

Do corticosteroid injections compromise rotator cuff tendon healing after arthroscopic repair?

Background

Rotator cuff tears are associated with capsular contraction and stiffness that should be restored before surgical repair. Corticosteroid injections (CSIs) are frequently used as conservative treatments before surgical repair. This study aimed to determine the influence of preoperative and postoperative CSIs on clinical and anatomic outcomes after rotator cuff repair.

Methods

The authors analyzed the records of 257 patients who had arthroscopic rotator cuff repair, of whom 212 were evaluated at 3.1 ± 1.0 years (median, 2.9 years; range, 1.4-7.1 years) by clinical (Constant score) and ultrasound (Sugaya classification) examinations. Univariable and multivariable regressions were performed to determine associations between outcomes and administration of preoperative and postoperative CSIs, patient characteristics, and tendon characteristics.

Results

The Constant scores improved from 56.4 ± 15.1 to 80.8 ± 12.5. Multivariable regression confirmed that postoperative scores were associated with postoperative CSIs (P < .001), preoperative scores (P < .001), gender (P < .001), and fatty infiltration (P < .005). Retears (Sugaya types IV-V) were observed in 27 shoulders (13%). Multivariable regression clarified that retear rates were associated only with postoperative CSIs (P = .007) and stage 3 fatty infiltration (P = .001). Adjusting for confounders, an additional postoperative CSI would decrease scores by 4.7 points and double retear risks.

Discussion

Preoperative CSIs had no influence on clinical scores and retear rates, whereas postoperative CSIs were associated with lower scores and more retears. Although we can infer that preoperative CSIs do not affect outcomes, we cannot determine whether postoperative CSIs compromised outcomes or were administered in patients who had already poor outcomes. Our findings may resolve controversies about the administration of preoperative CSIs.

The Effects of Glucocorticoid on Tendon and Tendon Derived Cells

Glucocorticoids are generally used to relieve pain and/or inflammation in a wide variety of musculoskeletal disorders including osteoarthritis, inflammatory arthritis, tendinopathy and degenerative spine disease. Glucocorticoids reduce tendon derived cell proliferation in vitro and reduce extracellular matrix synthesis both in vitro and in vivo, in particular type I collagen synthesis. Glucocorticoids also appear to result in acute deleterious changes in healthy in vivo tendon including collagen necrosis, collagen disorganisation and inflammatory cell infiltration; while the overall effect of glucocorticoid administration on the mechanical properties of healthy in vivo tendon are generally negative. Overall the existing in vitro and in vivo evidence suggests that glucocorticoids should be used with caution in treating painful tendinopathy. Certainly a real need exists to follow up the long term clinical effects of glucocorticoid in treating tendinopathy, as there is currently a paucity of evidence in this area. However in this context while the short term benefits are clear, glucocorticoids remain a useful treatment option provided they are used in the right patients in sensible moderation.

Effectiveness of prolotherapy in the treatment of chronic rotator cuff lesions

BACKGROUND

Rotator cuff lesions are one of the major causes of shoulder pain and dysfunction. Numerous non-surgical treatment modalities have been described for chronic rotator cuff lesions, but the debate continues over the optimal procedure. The aim of this report is to present the results of prolotherapy in the treatment of chronic refractory rotator cuff lesions.

HYPOTHESIS

Dextrose prolotherapy will reduce pain and improve shoulder function and patient satisfaction.

MATERIAL AND METHODS

We recruited 120 patients with chronic rotator cuff lesions and symptoms that persisted for longer than 6 months. Patients were divided into two groups: one treated with exercise (control group; n=60) and the other treated with prolotherapy injection (prolotherapy group; n=60). In the latter, ultrasound-guided prolotherapy injections were applied under aseptic conditions. In the former, patients received a physiotherapy protocol three sessions weekly for 12 weeks. Both groups were instructed to carry out a home exercise program. Clinical assessment of shoulder function was performed using a visual analog scale (VAS) for pain, Shoulder Pain and Disability Index (SPADI), Western Ontario Rotatory Cuff (WORC) Index, patient satisfaction, and shoulder range of motion. Patients were examined at baseline, weeks 3, 6, and 12, and last follow-up (minimum of one year).

RESULTS

A total of 101 patients (44 controls and 57 in the prolotherapy group) completed all study protocols and were included in the study. Using a within-group comparison, both groups achieved significant improvements over baseline, as measured by the VAS, SPADI, WORC index, and shoulder range of motion (P<0.001). Using a between-group comparison, a significant difference was found in the VAS scores at baseline, weeks 3, 6, and 12, and last follow-up. In addition, significant differences were found in the SPADIs and WORC indices at weeks 6 and 12 and the last follow-up. Significant differences were found in shoulder abduction and flexion at week 12 and last follow-up, and in internal rotation at last follow-up. However, no significant was found in external rotation at any follow-up period. In the prolotherapy group, 53 patients (92.9%) reported excellent or good outcomes; in the control group, 25 patients (56.8%) reported excellent or good outcomes.

CONCLUSION

Prolotherapy is an easily applicable and satisfying auxiliary method in the treatment of chronic rotatory cuff lesions.

STUDY TYPE

Randomized prospective comparative trial.

LEVEL OF EVIDENCE

Level of evidence 1.

Distal Biceps Tendinopathy: Conservative Treatment

Background

Non-traumatic distal biceps tendinopathy related to overuse, has not been previously reported in the literature. We describe the symptoms and signs, a novel injection technique onto the bicipital tuberosity of the radius and outcomes of this treatment.

Materials and Methods

We retrospectively reviewed the clinical notes of 20 patients (24 elbows), in whom the diagnosis of distal biceps tendinopathy was made. Twenty-two of 24 elbows were treated with one or more cortisone injections. The patients were followed up via a telephonic questionnaire.

Results

Average duration of follow-up was 3 years and 4 months. Eighteen elbows returned to full function. Five elbows (four patients) had partial resolution of symptoms, and one had no relief. In these six elbows, symptoms had been ongoing for ≥ 8 months prior to injection.

Conclusion

Distal biceps tendinopathy is often misdiagnosed. The majority of cases respond well to steroid injections without the risk of rupture or neurological injury. Resolution of pain with restoration to previous function is more likely when symptoms have been present for less than 8 months.

Clinical benefits and drawbacks of local corticosteroids injections in tendinopathies

INTRODUCTION

local glucocorticoids injections are widely administered for the treatment of tendinopathies. positive results have been observed in some tendinopathies but not in others. moreover, worsening of symptoms, and even spontaneous tendon ruptures has been reported. the characteristics of the tendinopathies, the clinical peculiarities of the patient, and the technique used to administer glucocorticoids, can influence the therapeutic response. Areas covered: After reviewing the pertinent literature on the clinical results, basic information, both on the pathogenesis of tendinopathies and the effects of glucocorticoids on tendons, is reported. The pharmacological properties of glucocorticoids are useful to counteract some pathogenetic mechanisms of tendinopathies. However, several experimental studies suggest that the direct action of glucocorticoids on tendons is detrimental. Loss of collagen organization, impaired viability of fibroblasts, depletion of stem cells pool, and reduced mechanical properties have been observed. Expert opinion: Drawbacks of local glucocorticoids injections could be predicted on an individual basis, after a careful appraisal of patient characteristics and concomitant medications, along with the specific stage of tendon disease.

In vitro toxicity of local anaesthetics and corticosteroids on supraspinatus tenocyte viability and metabolism

Background/Objective

The purpose of this study was to evaluate supraspinatus tenocyte viability and metabolism in explants exposed to various local anaesthetics and corticosteroids. Our hypothesis was that the tendons exposed to these common injectates would have significantly decreased cell viability and metabolism compared with controls.

Methods

Supraspinatus tendon explants were obtained from dogs, placed in a culture media, and randomly assigned to one of the following groups: culture media only (control), 1% lidocaine, 0.5% lidocaine, 0.25% bupivacaine, 0.125% bupivacaine, 0.0625% bupivacaine, betamethasone acetate (5 mg), methylprednisolone acetate (40 mg), or triamcinolone acetonide (40 mg). Cell viability was determined on Days 1 and 7 after culture treatment using calcein AM (live cell) and Sytox Blue (dead cell) stains. Tissue metabolism was assessed on Days 1 and 7 using the resazurin blue metabolic assay. Significant differences were evaluated using a one-way analysis of variance with Tukey post hoc analysis.

Results

Compared with the controls, there were significant decreases in cell viability noted at Days 1 and 7 in tenocytes exposed to 1% lidocaine, betamethasone, and methylprednisolone. Significant decreases in cell metabolism were also noted at Days 1 and 7 in those groups. Treatment with 0.125% bupivacaine, 0.0625% bupivacaine, and triamcinolone demonstrated no decrease in cell viability or metabolism when compared with controls at any time point.

Conclusion

This data confirms that peritendinous injection of commonly used local anaesthetics and corticosteroids results in significant supraspinatus tenotoxicity in vitro. Further in vivo studies are required before making definitive clinical recommendations.

Efficacy of a Subacromial Corticosteroid Injection for Persistent Pain After Arthroscopic Rotator Cuff Repair

BACKGROUND

Corticosteroid injections have been widely used for reducing shoulder pain. However, catastrophic complications induced by corticosteroid such as infections and tendon degeneration have made surgeons hesitant to use a corticosteroid injection as a pain control modality, especially during the postoperative recovery phase.

PURPOSE

To determine the effectiveness and safety of a subacromial corticosteroid injection for persistent pain control during the recovery period and to analyze the factors causing persistent pain after arthroscopic rotator cuff repair.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A total of 458 patients who underwent arthroscopic rotator cuff repair were included in this study. Patient-specific parameters, tear size and pattern, and pain intensity were reviewed. Seventy-two patients were administered a postoperative subacromial corticosteroid injection under ultrasound guidance. The corticosteroid injection was administered to patients who awakened overnight because of constant severe shoulder pain or whose pain was exacerbated at the time of rehabilitation exercises within 8 weeks after surgery. Pain intensity, patient satisfaction, and functional outcomes using the American Shoulder and Elbow Surgeons (ASES) and Constant scores were compared between the patients with and without a subacromial corticosteroid injection. The retear rate was evaluated with magnetic resonance imaging at 6 months postoperatively.

RESULTS

In patients with an injection, the mean (±SD) visual analog scale for pain (pVAS) score was 7.7 ± 1.2 at the time of the injection. This significantly decreased to 2.3 ± 1.4 at the end of the first month after the injection, demonstrating a 70.2% reduction in pain (P < .01). At 3 months after the injection, the mean pVAS score was 1.2 ± 1.8. Functional outcomes at final follow-up showed no significant differences between patients with and without an injection (ASES score: 90.1 ± 14.6 with injection, 91.9 ± 8.2 without injection [P = .91]; Constant score: 89.1 ± 12.9 with injection, 84.5 ± 13.0 without injection [P = .17]). Patients with an injection showed no significant increase in the retear rate (6.8% with injection, 18.4% without injection; P = .06). According to the tear pattern, L-shaped rotator cuff tears (41.8%) showed a higher occurrence of severe postoperative persistent pain. Preoperative shoulder stiffness was revealed as a predisposing factor for persistent pain (odds ratio, 0.2; P = .04).

CONCLUSION

A subacromial corticosteroid injection can be considered as a useful and safe modality for the treatment of patients having severe persistent pain during the recovery phase after arthroscopic rotator cuff repair.

Immunobiological factors aggravating the fatty infiltration on tendons and muscles in rotator cuff lesions

Rotator cuff lesions (RCLs) are a common cause of shoulder pain and dysfunction. The rotator cuff tendons can degenerate and/or tear from the greater tuberosity of the humerus, which is associated with several anatomical, physiological, biochemical, and molecular changes in tendon and muscle. In this article, these pathways are critically reviewed and discussed with various management strategies of RCLs. The article also highlights the immunobiological responses following the RCL and the inherent repair mechanisms elicited by the body. The greatest difficulty in treating this pathology is that the muscle can undergo irreversible fatty infiltration in the setting of chronic tears that is associated with poor surgical outcomes. The article also investigates the key molecular pathways of the muscle homeostasis (mTOR, Rho kinase, AMPK, and Ca(2+)) with the energy metabolism to propose a possible mechanism for fatty infiltration. Future research is warranted to target the key players of these pathways in the management of fatty infiltration and thus RCL.

Calcific tendinitis of the rotator cuff: state of the art in diagnosis and treatment

Calcific tendinitis is a painful shoulder disorder characterised by either single or multiple deposits in the rotator cuff tendon. Although the disease subsides spontaneously in most cases, a subpopulation of patients continue to complain of pain and shoulder dysfunction and the deposits do not show any signs of resolution. Although several treatment options have been proposed, clinical results are controversial and often the indication for a given therapy remains a matter of clinician choice. Herein, we report on the current state of the art in the pathogenesis, diagnosis and treatment of calcific tendinitis of the rotator cuff.

Clinical evidence in the treatment of rotator cuff tears with hyaluronic acid

PURPOSE

the aim of this quantitative review is to document potential benefit and adverse effects of hyaluronic acid (HA) injection into the shoulder with rotator cuff tears.

METHODS

a systematic literature search was performed in english PubMed, Medline, Ovid, Google Scholar and Embase databases using the combined key words "hyaluronic acid", "rotator cuff tear", "hyaluronate", "shoulder", "viscosupplementation", with no limit regarding the year of publication. Articles were included if they reported data on clinical and functional outcomes, complications in series of patients who had undergone HA injection for management of rotator cuff tears. Two Authors screened the selected articles for title, abstract and full text in accordance with predefined inclusion and exclusion criteria. The papers were accurately analyzed focusing on objective rating scores reported.

RESULTS

a total of 11 studies, prospective, 7 were randomized were included by full text. A total of 1102 patients were evaluated clinically after different HA injection compare with corticosteroid injection, physically therapies, saline solution injection and control groups. The use of HA in patients with rotator cuff tears improve VAS and functional score in all trials that we have analyzed.

CONCLUSION

intra-articular injection with HA is effective in reducing pain and improving function in shoulder with rotator cuff tears and without severe adverse reaction.

LEVEL OF EVIDENCE

Level I.

Detrimental Effect of Repeated and Single Subacromial Corticosteroid Injections on the Intact and Injured Rotator Cuff: A Biomechanical and Imaging Study in Rats

BACKGROUND

The effect of corticosteroids on tendons is poorly understood, and current data are insufficient and conflicting.

PURPOSE

To evaluate the effects of corticosteroid injections on intact and injured rotator cuffs (RCs) through biomechanical and radiographic analyses in a rat model.

STUDY DESIGN

Controlled laboratory study.

METHODS

A total of 70 rats were assigned to 7 groups. Uninjured rats (no tear) received either a single saline injection, a single methylprednisolone acetate (MTA) injection, or triple MTA injections. Injured rats (unilateral supraspinatus injury) received either a single saline injection, triple saline injections, a single MTA injection, or triple MTA injections (injections were subacromial; repeat injections were administered weekly). Rats were sacrificed 1 week after final injection. Shoulders were harvested and grossly inspected, and the supraspinatus tendon was evaluated biomechanically. Bone density at the tendon insertion site on the greater tuberosity was assessed by micro-computed tomography.

RESULTS

Intact RCs exposed to triple MTA injections had significantly decreased maximal load and stiffness compared with the control group (14.43 vs 21.25 N and 8.21 vs 16.6 N/mm, respectively; P < .05). Injured RCs exposed to steroid treatment had significantly lower maximal load (single saline: 10.91 N, single steroid: 8.43 N [P < .05]; triple control: 15.77 N, triple steroid: 11.65 N [P < .05]) compared with the control at 3 weeks. Greater tuberosity volume density and connectivity density were significantly lower in undamaged rats after triple MTA injection (P < .05).

CONCLUSION

The study results clearly showed that repeated doses of corticosteroids significantly weaken rat RC and negatively affect bone quality in addition to possibly causing deterioration of the osteotendinous junction. However, data retrieved from animals must be scrupulously analyzed before extrapolation to humans. As such, the potential benefits and harms of subacromial corticosteroid treatment must be considered before administration.

CLINICAL RELEVANCE

The potential benefit and detrimental effects of corticosteroid injection should be thoroughly considered before it is administered subacromially in patients with RC injuries.

Effects of corticosteroids and hyaluronic acid on torn rotator cuff tendons in vitro and in rats

Corticosteroids (CS) or hyaluronic acid (HA) is used in subacromial injection for the conservative treatment of rotator cuff tears (RCT); this study addresses the question of how CS and HA affect the tendon tissue and fibroblasts in vitro and in rats. Cell proliferation assays were performed in human tendon fibroblasts from RCT. Rats underwent surgery to create RCT, and the surgical sites were injected with CS or HA. The rotator cuff tendons were subjected to biomechanical testing, microscopic and immunohistochemical analysis of proliferating cell nuclear antigen (PCNA), and ultrastructural analysis. Cell proliferation was significantly decreased with CS in vitro (p < 0.05). Maximal load of CS-treated tendons was significantly decreased compared with that of HA-treated tendons (p < 0.05), as well as PCNA(+) cells at 2 weeks (p < 0.05). Ultrastructural observations of the CS-treated rats detected apoptosis of tendon fibroblasts 24 h after surgery. Histological and biomechanical data 4 weeks after surgery were not significant among the three groups. Unlike HA, CS caused cell death, and inhibition of the proliferation of tendon fibroblasts, leading to a delay of tendon healing involved and a subsequent decrease of biomechanical strength at the surgical site.

Does microvascularization of the footprint play a role in rotator cuff healing of the shoulder?

BACKGROUND

The aim of the study was to evaluate the relationship between bone microvascularization of the footprint and tendon integrity after rotator cuff repair of the shoulder.

METHODS

Forty-eight patients (mean age, 59 years; ±7.9) with a chronic rotator cuff tear underwent a tendon repair with a single-row technique and were studied prospectively. A core obtained from the footprint during the procedure allowed determination of the bone's microvascularization with an immunohistochemistry technique using anti-CD34 antibodies. Clinical evaluation was performed at a minimum of 12-month follow-up, and rotator cuff integrity was assessed with ultrasound according to Sugaya's classification.

RESULTS

At a mean follow-up of 13 months, the Constant score improved from 40 to 75 points; American Shoulder and Elbow Surgeons score, from 59 to 89 points; and subjective shoulder value, from 38% to 83% (P < .001). Ultrasound identified 18 patients with Sugaya type I healing, 27 patients with type II, and 3 patients with type IV. No patients showed Sugaya type III or V repairs. The rate of microvascularization of the footprint was 15.6%, 13.9%, and 4.2% for type I, II, and IV tendon integrity, respectively (I vs. II, P = .22; II vs. IV, P = .02; I vs. IV, P = .0022). Patients with a history of corticosteroid injection had a lower rate of microvascularization than the others (10.3% vs. 16.2%; P = .03).

CONCLUSIONS

Even if overall satisfactory clinical outcomes are achieved after a rotator cuff repair, bone microvascularization of the footprint plays a role in rotator cuff healing. A lower rate of microvessels decreases the tendon integrity and healing potential after repair.

A multi-center, double-blind, randomized, placebo-controlled trial protocol to assess Traumeel injection vs dexamethasone injection in rotator cuff syndrome: the TRAumeel in ROtator cuff syndrome (TRARO) study protocol

BACKGROUND

Shoulder pain is a common musculoskeletal symptom with a wide range of potential causes; however, the majority of conditions can be managed with conservative treatment. The aim of this study is to assess the efficacy and safety of Traumeel injections versus corticosteroid injections and placebo in the treatment of rotator cuff syndrome and bursitis and expand the current evidence base for the conservative treatment of rotator cuff syndrome.

METHODS/DESIGN

This is a multi-center, randomized, double-blind, 16-week, three-arm, parallel-group, active- and placebo-controlled trial to assess the efficacy and safety of Traumeel 2 ml injection versus dexamethasone 8 mg injection versus placebo (saline solution). Patients will be randomly allocated to Traumeel, dexamethasone or placebo in a 2:2:1 randomization. After 1 week screening, patients will receive 3 injections at weekly intervals (days 1, 8 and 15) with additional follow-up assessments on day 22, a telephone consultation in week 9 and a final visit at week 15. Male and female patients aged 40 to 65 years, inclusive, will be recruited if they have acute episodes of chronic rotator cuff syndrome and/or bursitis. Patients with calcifications in the shoulder joint or a complete rotator cuff tear will be excluded. At least 160 patients will be recruited. All subacromial injections will be performed under ultrasound guidance utilizing a common technique. The only rescue medication permitted will be paracetamol (acetaminophen), with usage recorded. The primary endpoint is change from baseline in abduction-rotation pain visual analog scale (0-100 mm scale, 0 corresponds to no pain and 100 to extreme pain) at day 22 (Traumeel injections versus dexamethasone injections) for active external rotation. Secondary efficacy parameters include range of motion, disability of arm, shoulder, hand score and patient's/investigator's global assessment. Clinical efficacy will be assessed as non-inferiority of Traumeel with respect to dexamethasone regarding the primary efficacy parameter.

DISCUSSION

It is hoped that the results of this trial will expand the treatment options and evidence base available for the management of rotator cuff disease.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01702233 . EudraCT number: 2012-003393-12.

Effect of a single subacromial prednisolone injection in acute rotator cuff tears in a rat model

PURPOSE

This study examined the early effect of a subacromial steroid injection on injured rotator cuff tendon.

METHODS

Forty rats were allocated into two groups: a steroid injection (group 1) and no injection as control (group 2). A full-thickness defect was made at the unilateral infraspinatus tendon in both groups. A single dose of methylprednisolone was injected in steroid group. The tendon was harvested at 1, 3, 7, 14, and 42 days after surgery; gene expression and immunohistochemical study were performed for type-I/III collagen, tumour necrosis factor (TNF)-α, and extracellular matrix molecules.

RESULTS

The type-III to type-I collagen ratio was at 7 days higher in the steroid group than that in the control group and decreased to the control level at 14 days and was maintained until 42 days. The general expression of the MMPs and TIMPs between two groups showed similar pattern regardless of the steroid injection. The gene expression of aggrecan and fibronectin in the steroid group was significantly higher than that in the control group (p < 0.05) at 3 days after surgery. They decreased to the equal level with control group at 7 days after surgery. Both groups showed no significant difference between aggrecan and fibronectin until 42 days after surgery (n.s.).

CONCLUSIONS

A subacromial steroid injection may alter the collagen composition and extracellular matrix and interfere with the healing process in an acute tear of rat infraspinatus tendon at the early phase after the injection. However, these alterations seem to become normalized after the early inflammatory healing phase.

Effects of repeated steroid injection at subacromial bursa with different interval

Objective

To evaluate the effects of repeated steroid injection at subacromial bursa with different interval for patient with periarticular shoulder disorder.

Methods

Group A (n=10) received subacromial bursa injection only on their first visit, group C (n=10) received the injection on their first visit and one week later, and group B (n=10) received the injection on their first visit and two weeks later. All injections were done with a combination of 40 mg (1.0 mL) of triamcinolone and 5.0 mL 0.5% lidocaine (6 mL total). We examined the active range of motion (AROM) of the shoulder joint, visual analogue scale (VAS), and shoulder disability questionnaire (SDQ) at baseline at 1, 2, and 4 weeks after the initial injection.

Results

In VAS, comparing the changes in VAS between groups, group B showed significant improvements compared with group A or C at 4 weeks after the initial injection (p<0.05). In SDQ, comparing the changes in SDQ between the groups, group B and C showed more improvement than group A at 4 weeks after the initial injection, but these results were not statistically significant (p>0.05). In AROM, comparing the changes in AROM of external rotation between groups, group B and C showed significant improvement compared with group A at 4 weeks after the initial injection (p<0.05).

Conclusion

It may be more effective in pain relief for patients with periarticular disorder to receive subacromial bursa injections twice with 2-week interval, as opposed to once.

Intra-articular infiltration therapy for patients with glenohumeral osteoarthritis: A systematic review of the literature

Background:

Conservative treatments are especially in patients with glenohumeral osteoarthritis (GH-OA) important, since shoulder arthroplasty has its limitations. In this systematic review, we will evaluate the current evidence regarding the efficacy of intra-articular (IA) infiltration treatment options in patients with GH-OA.

Materials and Methods:

The following databases are searched: Pubmed/Medline, Cochrane Clinical Trial Register, Embase and the WHO clinical trial register. All IA injection products used for the treatment of shoulder OA in humans are included.

Results:

A total of 8 studies could be included in this review. Hyaluronic acid (HA) showed effect sizes of 2.07, 2.02 and 2.11 at 6, 12 and 26 weeks follow-up, respectively. Placebo (1.60, 1.82 and 1.68) also showed stable effect sizes at the same time points. The efficacy of corticosteroids (CS) decreased rapidly at follow-up (1.08, 0.43 and 0.19). Although statistical significant, the maximum difference in effect sizes between HA and placebo was only 0.43 with absolute values between 2.0 and 6.4 on a 100-point visual analogue score for pain.

Conclusion:

IA treatment with HA has a good efficacy at follow-up compared to baseline. However, the difference in efficacy between HA and placebo never reaches the minimal clinically important difference at any of the follow-up points. We are not able to give clear recommendations for the use of IA CS injections in patients with GH-OA. In future research, we recommend focusing on sufficiently powered randomized trials to compare the efficacies of HA, CS, placebo and other IA treatment options in patients with GH-OA.

Dose- and time-dependent effects of triamcinolone acetonide on human rotator cuff-derived cells

Objectives

To investigate the appropriate dose and interval for the administration of triamcinolone acetonide (TA) in treating tendinopathy to avoid adverse effects such as tendon degeneration and rupture.

Methods

Human rotator cuff-derived cells were cultured using three media: regular medium (control), regular medium with 0.1 mg/mL of TA (low TA group), and with 1.0 mg/mL of TA (high TA group). The cell morphology, apoptosis, and viability were assessed at designated time points.

Results

In the low TA group, the cells became flattened and polygonal at seven days then returned to normal at 21 days. The cell apoptosis ratio and messenger ribonucleic acid expression of caspase-3, 7, 8, and 9 increased, and viability was reduced in the low and high groups at seven days. In the low TA group, apoptosis and viability returned to normal at 21 days, however, in the high TA group, the cell morphology, apoptosis ratio, caspase-3, 7, 8, and 9 and viability did not return by day 21. Re-administration was performed in the low TA group at 7-, 14-, and 21-day intervals, and cell viability did not return to the control level at the 7- and 14-day intervals.

Conclusion

A 0.1 mg/mL dose of TA temporarily decreased cell viability and increased cell apoptosis, which was recovered at 21 days, however, 1 mg/mL of TA caused irreversible damage to cell morphology and viability. An interval > three weeks was needed to safely re-administer TA. These findings may help determine the appropriate dose and interval for TA injection therapy.

Cite this article: Bone Joint Res 2014;3:328–34.

Subacromial triamcinolone acetonide, hyaluronic acid and saline injections for shoulder pain an RCT investigating the effectiveness in the first days

Background

Subacromial impingement is a common cause of shoulder complaints in general practice. When the initial treatment with acetaminophen and low dose Non Steroidal Anti Inflammatory Drugs fails, triamcinolone acetonide injections are commonly used. Triamcinolone acetonide injections are effective at four to six weeks. Little is known about the pain relief effect of triamcinolone acetonide injections in the first days after injection and the effect of repeated injection. In this study we investigate the effect of triamcinolone acetonide injections compared to hyaluronic acid and NaCl injections using a pain diary.

Methods

159 Patients recruited for an RCT comparing the effect of subacromial injections of triamcinolone acetonide, hyaluronic acid and sodium chloride (NaCl) were used in this study. They were blinded for their treatment and could receive up to three injections. Primary outcome consisted of the patient perceived pain on a VAS score recorded on a daily basis during 21 days following injection. Secondary outcome consisted of the amount of taken escape medication following injection and adverse effects.

Results

All patients received the first injection. 150 patients also received the second and third injections. 97% Of the paper and pencil pain diaries were returned for data analysis.

The triamcinolone acetonide group showed the largest decrease in pain on the VAS scores after injection compared to the hyaluronic acid and NaCl group in the first week after injection. The reduction in pain was best achieved after the first injection, the second triamcinolone acetonide injection showed a further reduction in pain. The third triamcinolone acetonide injection only showed a slight improvement in pain reduction.

Conclusions

In this study we could show a booster effect in pain reduction after repeated triamcinolone acetonide injection. The triamcinolone acetonide group showed a faster reduction in pain after injection compared to the hyaluronic acid and NaCl group. The effect was best seen after the first and second triamcinolone acetonide injection, it is therefore questionable whether it is necessary to repeat triamcinolone acetonide injections more than two times.

Trial registration

ISRCTN51511455. Registered 20 December 2005

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2474-15-352) contains supplementary material, which is available to authorized users.

MRI findings of rotator cuff myotendinous junction injury

OBJECTIVE

The purpose of this article is to describe the MRI features of rotator cuff myotendinous junction injuries.

MATERIALS AND METHODS

We retrospectively identified MRI cases with myotendinous junction injury of the rotator cuff muscles and reviewed clinical, imaging, and surgical records. MR images were reviewed independently by two musculoskeletal radiologists to grade myotendinous junction injuries (strain, partial tear, or complete tear) and to assess for concurrent tendon tears (partial or full thickness) and bone changes (fracture or contusion).

RESULTS

The final study group comprised 16 subjects. The mean age was 38 years, with a majority of men (56%). The left shoulder was affected in 56% of subjects, with the dominant upper limb affected in 50%. The mean time between symptoms and MRI was 19 days. Subjects reported heavy lifting (19%), landing on the arm after a fall (19%), or prior shoulder therapeutic injection (25%). Myotendinous junction injuries affected the infraspinatus muscle (50%), followed by the supraspinatus (31%), subscapularis (25%), and teres minor (19%) muscles. About one fifth of subjects presented with more than one muscle affected, and 94% did not present with tears of the corresponding tendons. Most myotendinous junction injuries were strains (80%), followed by partial tears (20%). No complete tears were identified. There was no correlation between myotendinous junction injury and the presence of bone changes or the presence of tendon tears (p > 0.05).

CONCLUSION

Rotator cuff myotendinous junction injuries affect mostly the infra-spinatus and supraspinatus muscles, usually in a strain pattern and without tear of the corresponding tendon attachment.