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.

Assessment of description and implementation fidelity of clinical trials involving exercise-based treatment in individuals with rotator cuff tears: a scoping review

BACKGROUND

For evidence-based practice, clinicians and researchers can rely on well-conducted randomized clinical trials that exhibit good methodological quality, provide adequate intervention descriptions, and implementation fidelity.

OBJECTIVE

To assess the description and implementation fidelity of exercise-based interventions in clinical trials for individuals with rotator cuff tears.

METHODS

A systematic search was conducted in PubMed, Embase, CINAHL, LILACS, Cochrane Library, Web of Science, SCOPUS and SciELO. Randomized clinical trials that assessed individuals with rotator cuff tears confirmed by imaging exam were included. All individuals must have received an exercise-based treatment. The methodological quality was scored with the Physiotherapy Evidence Database (PEDro) scale. The Template for Intervention Description and Replication (TIDieR) checklist and the National Institutes of Health Behaviour Change Consortium (NIHBCC) were used to assess intervention description and implementation fidelity, respectively.

RESULTS

A total of 13 studies were included. Despite their adequate methodological quality, the description of the intervention was poor with TIDieR scores ranging from 6 to 15 out of 24 total points. The TIDieR highest-scoring item was item 1 (brief name) that was reported in all studies. Considering fidelity, only one of the five domains of NIHBCC (i.e., treatment design) reached just over 50%.

CONCLUSION

Exercise-based interventions used in studies for individuals with rotator cuff tears are poorly reported. The description and fidelity of the intervention need to be better reported to assist clinical decision-making and support evidence-based practice.

Risk of Infection After Total Knee or Hip Arthroplasty After Receipt of Multiple Corticosteroid or Hyaluronic Acid Injections

BACKGROUND

Few studies have assessed the relationship between the quantity of preoperative corticosteroid injections (CSIs) or hyaluronic acid injections (HAIs) and postoperative infection risk after total knee or hip arthroplasty (TKA, THA). We aimed to (1) determine whether the number of injections administered before TKA/THA procedures is associated with postoperative infections and (2) establish whether infection risk varies by injection type.

METHODS

This retrospective cohort study included 230,487 THAs and 371,511 TKAs from the 2017 to 2018 Medicare Limited Data Set. The quantity of CSI or HAI, defined as receiving either CSI or HAI ≤2 years before TKA/THA, was identified and categorized as 0, 1, 2, or >2. The primary outcome was 90-day postoperative infection. Multivariable regression models measured the association between the number of injections and 90-day postoperative infection. Odds ratios and 95% confidence intervals were reported.

RESULTS

The percentage of THA patients receiving 1, 2, and >2 preoperative CSIs was 6.1%, 1.6%, and 0.8%, respectively. Receiving >2 CSIs within 2 years before THA was associated with higher odds of 90-day postoperative infection (odds ratios = 1.74, 95% CI = 1.11 to 2.74, P = 0.02). The percentage of TKA patients receiving 1, 2, and >2 CSIs was 3.0%, 1.2%, and 1.1%, respectively. For HAIs in TKA patients, percentage receiving injections was 98.3%, 0.6%, 0.2%, and 0.9%, respectively. Quantity of CSIs or HAIs administered was not associated with postoperative infection among TKA patients.

CONCLUSION

Patients receiving >2 injections before THA had higher odds of 90-day postoperative infection. This finding was not observed in TKA patients. These results suggest that the use of >2 injections within 2 years of THA should be avoided.

Comparison of three common shoulder injections for rotator cuff tears: a systematic review and network meta-analysis

OBJECTIVE

To compare the clinical effectiveness of three common shoulder injections mentioned in the guidelines [corticosteroid, sodium hyaluronate (SH) and platelet-rich plasma (PRP)] on rotator cuff tears.

MATERIAL AND METHODS

The PubMed, Embase and Cochrane Library databases were systematically searched up to June 1, 2022, for randomized controlled trials (RCTs) and prospective studies on the three injection therapies for rotator cuff tears. The main results were pain relief and functional improvement at 1-5 months and over 6 months, pooled using a network meta-analysis and ranked by SUCRA score. The risk of bias of the included studies was assessed using the Cochrane Collaboration tool.

RESULTS

Twelve RCTs and 4 prospective studies comprising a total of 1115 patients were included in the review. Three prospective studies were judged to be at high risk of selection bias and performance bias, and one was considered as having a high risk of detection bias. SH injection ranked first in the short term in pain relief (MD: - 2.80; 95%CI - 3.91, - 1.68) and functional improvement (MD:19.17; 95%CI 12.29, 26.05), while PRP injection obtained better results in the long term in both pain relief (MD: - 4.50; 95%CI - 4.97, - 4.03) and functional improvement (MD:11.11; 95%CI 0.53,21.68).

CONCLUSIONS

PRP injection has the potential to successfully treat rotator cuff tears as an alternative to corticosteroids in the long term, in terms of either therapeutic efficiency or adverse effects, followed by SH injection. More research is needed to make high-quality recommendations on treatment options for injection treatments of rotator cuff tears.

Effects of Platelet-Rich Plasma in Tear Size Reduction in Partial-Thickness Tear of the Supraspinatus Tendon Compared to Corticosteroids Injection

OBJECTIVES

Corticosteroid (CS) injection is commonly used in partial-thickness rotator cuff tears to decrease pain. However, this could result in unwanted side effects, such as tendon rupture. Alternatively, platelet-rich plasma (PRP) injection is frequently used to treat tendinopathies because it enhances healing. This study aimed to compare the differences in tear size and functional scores between intralesional PRP and subacromial CS injections.

METHODS

Patients with symptomatic partial-thickness tears of the supraspinatus tendon who underwent conservative treatment for ≥ 3 months were enrolled. All patients underwent magnetic resonance imaging (MRI) to confirm the diagnosis. Fourteen and 15 patients were randomized to receive intralesional PRP and subacromial CS injections, respectively. Tears were measured in the coronal and sagittal planes. The patients underwent another MRI 6 months after the injection. Tear size was compared between the two MRI results. The American Shoulder and Elbow Surgeons Shoulder score (ASES) and Constant-Murley score (CMS) were also obtained.

RESULTS

The baseline data were similar between the groups. In the coronal plane, PRP and CS showed tear size reductions of 3.39 mm (P = 0.003) and 1.10 mm (P = 0.18), respectively. In the sagittal plane, PRP and CS showed tear size reductions of 2.97 mm (P = 0.001) and 0.76 mm (P = 0.29), respectively. Functional scores improved 6 months after injection in both groups, but PRP showed better functional scores than CS (P = 0.002 for ASES, P = 0.02 for CS).

CONCLUSION

Intralesional PRP injection can reduce the tear size in partial-thickness tears of the supraspinatus tendon. Subacromial steroid injection did not significantly affect the tear size. While CS improved functional scores compared with baseline, PRP resulted in better improvement 6 months post-injection. Trial registration Thai Clinical Trials Registry, TCTR20210428004. Registered 28 April 2021-retrospectively registered, TCTR20210428004 .

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.

Blood Flow in the Anterior Humeral Circumflex Artery Reflects Synovial Inflammation of the Shoulder Joint in Rotator Cuff Tears

Background

An association has been reported between rotator cuff tear and inflammation. We hypothesized that blood flow in the anterior humeral circumflex artery would reflect synovial inflammation in the shoulder. This study aimed to clarify the association of blood flow in the anterior humeral circumflex artery with synovial inflammation and shoulder pain in patients with rotator cuff tears.

Methods

In this prospective, cross-sectional study, tissue samples from the synovium in the rotator interval were obtained from 33 patients undergoing arthroscopic rotator cuff repair. Reverse transcription-polymerase chain reaction and real-time polymerase chain reaction were performed to determine the messenger RNA expression of inflammatory mediators, growth factors, and matrix metalloproteinases. Additional tissue samples were fixed for histologic evaluation. Before surgery, we measured the peak systolic velocity in the anterior humeral circumflex artery using pulse Doppler ultrasonography.

Results

The peak systolic velocity in the anterior humeral circumflex artery was positively correlated with the messenger RNA expression of interleukin 1β, interleukin 8, and matrix metalloproteinase 3 genes (r = 0.49, P = .004; r = 0.55, P = .001; and r = 0.39, P = .026, respectively), as well as histologic synovitis scores (r = 0.48, P = .005). Additionally, it was significantly higher in patients with resting pain than in those without resting pain (P = .048).

Conclusion

The peak systolic velocity in the anterior humeral circumflex artery is associated with the severity of synovial inflammation. Our results suggest that assessing the peak systolic velocity in the anterior humeral circumflex artery is useful for evaluating the severity of synovial inflammation.

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.

Management of Acute Rotator Cuff Tears

Acute, traumatic rotator cuff tears typically occur in younger patients with a fall on an outstretched hand, grabbing an object to catch oneself when falling, or a glenohumeral dislocation. These tears are best evaluated with MRI. Partial-thickness tears may be managed nonoperatively with physical therapy, NSAIDs, and injections. Full-thickness tears in most patients should be managed with surgical repair as soon as possible, with better outcomes shown when repaired within 4 months of injury.

Current updates in image-guided musculoskeletal interventions

Image-guided musculoskeletal interventions are frequently done in clinical practice. Even then, the literature regarding their effectiveness is relatively scarce. Image guidance adds value over the conventional landmark-based approach and should be preferred. We hereby try to list the commonly performed procedures along with the current practice guidelines regarding their clinical indications and periprocedural care.

A Historical Analysis of Randomized Controlled Trials in the Management of Pain in Rotator Cuff Tears

The aim of this analysis was to assess the quality of reporting of randomized controlled trials (RCTs) relating to pain management in rotator cuff (RC) tears. This review evaluated the quality of the studies in the literature regarding this topic through the use of some factors and trends. The online databases used to search all RCTs on the topic of RC surgery were Medline, Scopus, CINAHL, EMBASE, and CENTRAL. This research was completed in September 2020. To assess the quality of reports, the Consolidated Standards of Reporting Trials (CONSORT) and the modified Coleman methodology score (MCMS) were used. From the research, 262 articles emerged. Finally, 79 studies were included in this historical analysis. There were no statistically significant changes in MCMS across trials that included or did not include a CONSORT diagram (p = 0.10). A statistically significant difference in MCMS was discovered between papers produced prior to 2009 and publications produced after 2015 (p = 0.03). There was no association between the number of checklist items for each article and the Coleman score. During the years there has been a significant increase in both quantity and quality of RCTs relating to pain in RC tears.

Effects of steroid injection during rehabilitation after arthroscopic rotator cuff repair

Background

This study aims to compare the clinical outcomes of steroid injections during the rehabilitation period after arthroscopic rotator cuff repair (ACRC).

Methods

Among patients who underwent ARCR, 117 patients who met the inclusion and exclusion criteria were enrolled. Pain and range of motion (ROM) recovery at the 3-, 6-, and 24-month follow-up visits and functional outcome at the 24-month follow-up were compared between 45 patients who received ultrasound-guided subacromial steroid injection at postoperative week 4 or 6 and 72 patients who did not. Functional outcome was assessed using the American Shoulder and Elbow Surgeons (ASES) score and Constant score. Healing of the repaired tendon and retear were observed at the 6-month follow-up via magnetic resonance imaging (MRI) or computed tomography (CT) arthrography.

Results

At the 3-month follow-up, the steroid injection group showed lower visual analog scale scores than the control group (p<0.05) and showed faster recovery of forward flexion and internal rotation (p<0.05). From the 6-month follow-up, the two groups did not show differences in pain and ROM, and the ASES score and Constant score also did not significantly differ at the 24-month follow-up. The two groups did not differ in retear rate as determined by MRI or CT arthrography at the 6-month follow-up.

Conclusions

This study demonstrated that ultrasound-guided subacromial steroid injection at 4 or 6 weeks after ARCR leads to quick pain reduction and ROM recovery until 3 months after surgery. Therefore, subacromial steroid injection is speculated to be an effective and relatively safe method to assist rehabilitation.

Comparison of a Platelet-Rich Plasma Injection and a Conventional Steroid Injection for Pain Relief and Functional Improvement of Partial Supraspinatus Tears

Background

Partial supraspinatus tendon tears have frequently been treated using a subacromial corticosteroid injection or surgery. The clinical use of a platelet-rich plasma (PRP) injection is an alternative treatment method for the condition, despite the paucity of evidence of its efficacy.

Purpose

To compare pain relief, functional improvement, and complications after an intratendinous PRP injection versus a subacromial corticosteroid injection for partial supraspinatus tears.

Study Design

Randomized controlled trial; Level of evidence, 1.

Methods

A total of 32 patients with partial supraspinatus tears were randomly assigned to receive a leukocyte-poor PRP (LP-PRP) injection or a corticosteroid injection. One patient withdrew from the PRP group, leaving 15 patients in the PRP group and 16 patients in the corticosteroid group. The ultrasound-guided procedures were performed by a single experienced pain physician. Pain relief and functional improvement were evaluated using the visual analog scale (VAS) and the Oxford Shoulder Score (OSS), respectively. Treatment efficacy and complications were documented, and the 2 groups were compared at 1- and 6-month follow-up.

Results

There were no differences in VAS and OSS scores between the PRP and corticosteroid groups at 1-month follow-up. However, the PRP group had better scores than the corticosteroid group had on both the VAS and OSS at 6-month follow-up (VAS: 14.5 ± 15.4 vs 37.5 ± 24.9, respectively; OSS: 16.2 ± 3.9 vs 25.0 ± 10.2, respectively; P < .01 for both). Both groups showed significant improvement in VAS and OSS scores from before treatment to 1-month follow-up (mean difference, 35.67 and 11.47 points, respectively, for the PRP group; mean difference, 29.69 and 11.13 points, respectively, for the corticosteroid group; P < .01 for all). The VAS and OSS scores did not change significantly at 6-month follow-up in the corticosteroid group; however, the PRP group showed continued improvement in both VAS and OSS scores between 1- and 6-month follow-up (mean difference, 15.87 and 7.40 points, respectively; P < .01 for both). There were no complications in either group.

Conclusion

An injection using either a corticosteroid or LP-PRP resulted in a similar reduction in pain and improvement in function at 1 month in patients with a partial supraspinatus tear. However, PRP showed superior benefits over the corticosteroid at 6-month follow-up.

Progressive exercise compared with best-practice advice, with or without corticosteroid injection, for rotator cuff disorders: the GRASP factorial RCT

BACKGROUND

Rotator cuff-related shoulder pain is very common, but there is uncertainty regarding which modes of exercise delivery are optimal and the long-term benefits of corticosteroid injections.

OBJECTIVES

To assess the clinical effectiveness and cost-effectiveness of progressive exercise compared with best-practice physiotherapy advice, with or without corticosteroid injection, in adults with a rotator cuff disorder.

DESIGN

This was a pragmatic multicentre superiority randomised controlled trial (with a 2 × 2 factorial design).

SETTING

Twenty NHS primary care-based musculoskeletal and related physiotherapy services.

PARTICIPANTS

Adults aged ≥ 18 years with a new episode of rotator cuff-related shoulder pain in the previous 6 months.

INTERVENTIONS

A total of 708 participants were randomised (March 2017-May 2019) by a centralised computer-generated 1 : 1 : 1 : 1 allocation ratio to one of four interventions: (1) progressive exercise (n = 174) (six or fewer physiotherapy sessions), (2) best-practice advice (n = 174) (one physiotherapy session), (3) corticosteroid injection then progressive exercise (n = 182) (six or fewer physiotherapy sessions) or (4) corticosteroid injection then best-practice advice (n = 178) (one physiotherapy session).

MAIN OUTCOME MEASURES

The primary outcome was Shoulder Pain and Disability Index (SPADI) score over 12 months. Secondary outcomes included SPADI subdomains, the EuroQol 5 Dimensions, five-level version, sleep disturbance, fear avoidance, pain self-efficacy, return to activity, Global Impression of Treatment and health resource use. Outcomes were collected by postal questionnaires at 8 weeks and at 6 and 12 months. A within-trial economic evaluation was also conducted. The primary analysis was intention to treat.

RESULTS

Participants had a mean age of 55.5 (standard deviation 13.1) years and 49.3% were female. The mean baseline SPADI score was 54.1 (standard deviation 18.5). Follow-up rates were 91% at 8 weeks and 87% at 6 and 12 months. There was an overall improvement in SPADI score from baseline in each group over time. Over 12 months, there was no evidence of a difference in the SPADI scores between the progressive exercise intervention and the best-practice advice intervention in shoulder pain and function (adjusted mean difference between groups over 12 months -0.66, 99% confidence interval -4.52 to 3.20). There was also no difference in SPADI scores between the progressive exercise intervention and best-practice advice intervention when analysed at the 8-week and 6- and 12-month time points. Injection resulted in improvement in shoulder pain and function at 8 weeks compared with no injection (adjusted mean difference -5.64, 99% confidence interval -9.93 to -1.35), but not when analysed over 12 months (adjusted mean difference -1.11, 99% confidence interval -4.47 to 2.26), or at 6 and 12 months. There were no serious adverse events. In the base-case analysis, adding injection to best-practice advice gained 0.021 quality-adjusted life-years (p = 0.184) and increased the cost by £10 per participant (p = 0.747). Progressive exercise alone was £52 (p = 0.247) more expensive per participant than best-practice advice, and gained 0.019 QALYs (p = 0.220). At a ceiling ratio of £20,000 per quality-adjusted life-year, injection plus best-practice advice had a 54.93% probability of being the most cost-effective treatment.

LIMITATIONS

Participants and physiotherapists were not blinded to group allocation. Twelve-month follow-up may be insufficient for identifying all safety concerns.

CONCLUSIONS

Progressive exercise was not superior to a best-practice advice session with a physiotherapist. Subacromial corticosteroid injection improved shoulder pain and function, but provided only modest short-term benefit. Best-practice advice in combination with corticosteroid injection was expected to be most cost-effective, although there was substantial uncertainty.

FUTURE WORK

Longer-term follow-up, including any serious adverse effects of corticosteroid injection.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN16539266 and EudraCT 2016-002991-28.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 48. See the NIHR Journals Library website for further project information.

Progressive exercise compared with best practice advice, with or without corticosteroid injection, for the treatment of patients with rotator cuff disorders (GRASP): a multicentre, pragmatic, 2 × 2 factorial, randomised controlled trial

BACKGROUND

Corticosteroid injections and physiotherapy exercise programmes are commonly used to treat rotator cuff disorders but the treatments' effectiveness is uncertain. We aimed to compare the clinical effectiveness and cost-effectiveness of a progressive exercise programme with a single session of best practice physiotherapy advice, with or without corticosteroid injection, in adults with a rotator cuff disorder.

METHODS

In this pragmatic, multicentre, superiority, randomised controlled trial (2 × 2 factorial), we recruited patients from 20 UK National Health Service trusts. We included patients aged 18 years or older with a rotator cuff disorder (new episode within the past 6 months). Patients were excluded if they had a history of significant shoulder trauma (eg, dislocation, fracture, or full-thickness tear requiring surgery), neurological disease affecting the shoulder, other shoulder conditions (eg, inflammatory arthritis, frozen shoulder, or glenohumeral joint instability), received corticosteroid injection or physiotherapy for shoulder pain in the past 6 months, or were being considered for surgery. Patients were randomly assigned (centralised computer-generated system, 1:1:1:1) to progressive exercise (≤6 sessions), best practice advice (one session), corticosteroid injection then progressive exercise, or corticosteroid injection then best practice advice. The primary outcome was the Shoulder Pain and Disability Index (SPADI) score over 12 months, analysed on an intention-to-treat basis (statistical significance set at 1%). The trial was registered with the International Standard Randomised Controlled Trial Register, ISRCTN16539266, and EuDRACT, 2016-002991-28.

FINDINGS

Between March 10, 2017, and May 2, 2019, we screened 2287 patients. 708 patients were randomly assigned to progressive exercise (n=174), best practice advice (n=174), corticosteroid injection then progressive exercise (n=182), or corticosteroid injection then best practice advice (n=178). Over 12 months, SPADI data were available for 166 (95%) patients in the progressive exercise group, 164 (94%) in the best practice advice group, 177 (97%) in the corticosteroid injection then progressive exercise group, and 175 (98%) in the corticosteroid injection then best practice advice group. We found no evidence of a difference in SPADI score between progressive exercise and best practice advice when analysed over 12 months (adjusted mean difference -0·66 [99% CI -4·52 to 3·20]). We also found no evidence of a difference between corticosteroid injection compared with no injection when analysed over 12 months (-1·11 [-4·47 to 2·26]). No serious adverse events were reported.

INTERPRETATION

Progressive exercise was not superior to a best practice advice session with a physiotherapist in improving shoulder pain and function. Subacromial corticosteroid injection provided no long-term benefit in patients with rotator cuff disorders.

FUNDING

UK National Institute for Health Research Technology Assessment Programme.

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.

Ultrasonographic evaluation of chronic shoulder pain after breast cancer surgery: single center, cross-sectional study

Chronic shoulder pain is a common complication in breast cancer patients after surgery. Chronic shoulder pain after breast cancer surgery was formerly considered as neuropathic pain, however the pathophysiology including structural damages has not been assessed comprehensively. We hypothesized that the structural change could be one of the cause of shoulder pain after breast cancer surgery and evaluated various ultrasonography findings of the shoulder in breast cancer patients with chronic shoulder pain. Patients who were suffering from chronic shoulder pain on unilateral side for at least 3 months after breast cancer surgery were enrolled from a single tertiary hospital. Demographic and clinical data were collected at the baseline. Articular and adjacent structures of both shoulders (painful and contralateral side) were evaluated by ultrasonography. The ultrasonography findings were compared between painful and contralateral sides. Logistic regression analysis was performed to determine the factors associated with abnormal ultrasonography findings. Fifty-two female patients (average age of 55) were enrolled. Significantly more abnormal ultrasonography findings were observed in the painful side than in the contralateral side [39 (75.0%) vs 11 (21.2%), P < 0.001]. The coracohumeral ligament was significantly thicker in the painful side than in the contralateral side (2.48 ± 0.69 vs 1.54 ± 1.25 mm, P < 0.001); adhesive capsulitis was also more frequent in the painful side [14 (26.9%) vs 0, P < 0.001]. Furthermore, patients with a history of breast cancer surgery on the ipsilateral side were associated with abnormal ultrasonography findings and adhesive capsulitis. This study is the first to evaluate ultrasonography in patients with chronic shoulder pain after breast cancer surgery. The results showed that ultrasonography could reveal several structural problems in these patients.

A Historical Analysis of Randomized Controlled Trials in Rotator Cuff Tears

Background and objectives: Our research aimed to evaluate the quality of reporting of randomized controlled trials (RCTs) linked to rotator cuff (RC) tears. The present study analyzed factors connected to the quality of the RCTs and trends in the quality of reporting through time. Materials and Methods: The online databases used to search all RCTs on the topic of RC surgery completed until March 2020 were PubMed and Ovid (MEDLINE). The quality of reporting was evaluated using the modified Coleman methodology score (MCMS) and the consolidated standards of reporting trials (CONSORT). Results: The online search found 957 articles. Finally, 183 studies were included in the quantitative synthesis. A total of 97 (53%) of 183 studies had a level of evidence I and 86 (47%) of 183 studies had a level of evidence II, according to the Oxford Center of Evidence Based Medicine (EBM). A statistically significant difference in MCMS between articles written before 2010 and articles written after 2010 was found. Articles written after 2010 had, on average, the highest Coleman score. The average number of CONSORT checklist items for each article across all analyzed RCTs was 21.67. The 37 studies completed up to 2010 averaged a number of checklist items of 19.97 and the studies completed between 2011 and 2019 averaged a number of checklist items of 22.10. A statistically significant difference in the number of checklist items between articles written before 2010 and articles written after 2010 was found. Articles written after 2010 had on average more checklist items. However, low correlation (0.26) between the number of checklist items for each article and the respective Coleman score was found. On the other hand, articles with the CONSORT diagram had a significantly high Coleman score. Conclusions: An improvement in the quantity and quality of RCTs relating to RC surgery over the analyzed period was found.

A new pathophysiology of atraumatic rotator cuff tears: adduction restriction of the glenohumeral joint

Background

The pathophysiology of atraumatic rotator cuff tears (ATTs) has not been fully understood. Adduction restriction of the glenohumeral joint can cause pain and disability in patients with ATTs. We aimed to use our adduction test (pushing the humerus toward the side in the coronal plane with scapular fixation) to fluoroscopically measure the glenohumeral adduction angle (GAA) and to assess the effectiveness of adduction manipulation.

Materials and methods

Fifty-five patients with ATTs were included in the study. The GAAs of the patients vs. healthy subjects without ATTs were measured fluoroscopically and compared. During the test, patients showed restriction and expressed pain. The visual analog scale (VAS) score, passive range of motion (ROM), and the American Shoulder and Elbow Surgeons score at the initial visit were compared with those after adduction manipulation.

Results

Of the patients, 41 (75%) had positive adduction test results. A higher percentage of positive adduction test results was observed in smaller tears. The average GAA was –21.4° on the affected side, which was smaller than that on the unaffected side, at –2.8° (P < .001), and that in healthy subjects, at 4.8° (P < .001). After manipulation, the GAA was –0.8° (P < .001) and the VAS score, the American Shoulder and Elbow Surgeons score, and all ROM values significantly improved up to the level on the unaffected side.

Conclusion

Adduction restriction of the glenohumeral joint was identified in 75% of all the patients with ATTs. Adduction manipulation significantly reduces the VAS score and restores the ROM. Adduction restriction is considered a crucial pathophysiology of ATTs.

Clinical results of conservative management in patients with full-thickness rotator cuff tear: a meta-analysis

Background

Several systematic reviews have reported on the conservative treatment of full-thickness rotator cuff tears; however, clinical results of this treatment still remain determined.

Methods

PubMed, Cochrane Library, PEDro, and CINAHL databases were systematically searched for randomized clinical trials and observational studies. Two independent researchers reviewed a total of 2,981 articles, 28 of which met the criteria for inclusion in the study. Clinical outcome measures included Constant score, visual analog scale score for pain, range of motion, and short-form 36 questionnaires. The meta-analysis used a linear mixed model weighted with the variance of the estimate.

Results

The meta-analysis showed a significant improvement after surgery. Pain score is 26.2 mm (1 month) to 26.4 mm (3 months), and 24.8 mm (12 months) (P<0.05); active abduction: 153.2º (2 months), 159.0º (6 months), 168.1º (12 months) (P<0.05); Constant score: 67.8 points (2 months) to 77.2 points (12 months) (P<0.05); short-form 36 questionnaires "vitality" section: 57.0 points (6 months) to 70.0 points (12 months) (P<0.05).

Conclusions

Our data confirmed the effectiveness of conservative treatment in patients with full-thickness rotator cuff tears 12 months post-intervention. The results suggest that conservative treatment for patients with full-thickness rotator cuff tears should be the first line of treatment before considering surgery.

Rehabilitation Management of Rotator Cuff Injuries in the Master Athlete

Rotator cuff (RTC) injuries are common in master athletes, especially overhead athletes. Risk factors include aging and degeneration as nonmodifiable and volume of activity, muscle weakness, and loss of motion as modifiable. The clinical presentation involves limited range of motion (ROM), pain at rest and at night. Injury classification into traumatic versus nontraumatic and tendinopathy, partial or full-thickness tears helps to establish a treatment plan. RTC injury rehabilitation protocols are criteria-based, multimodal, and divided into four phases. The acute phase addresses pain, inflammation, ROM, and RTC protection. The recovery phase addresses kinetic chain abnormalities, flexibility, and strength, and the functional phase involves exercises directed toward specific sport activities. Return to sports is based on clinical recovery, kinetic chain principles, and adequate sports technique. Nonsurgical management is recommended in most cases, and surgical management is considered if symptoms progress, especially for full-thickness tears.

Surgery for rotator cuff tears

BACKGROUND

This review is one in a series of Cochrane Reviews of interventions for shoulder disorders.

OBJECTIVES

To synthesise the available evidence regarding the benefits and harms of rotator cuff repair with or without subacromial decompression in the treatment of rotator cuff tears of the shoulder.

SEARCH METHODS

We searched the CENTRAL, MEDLINE, Embase, Clinicaltrials.gov and WHO ICRTP registry unrestricted by date or language until 8 January 2019.

SELECTION CRITERIA

Randomised controlled trials (RCTs) including adults with full-thickness rotator cuff tears and assessing the effect of rotator cuff repair compared to placebo, no treatment, or any other treatment were included. As there were no trials comparing surgery with placebo, the primary comparison was rotator cuff repair with or without subacromial decompression versus non-operative treatment (exercises with or without glucocorticoid injection). Other comparisons were rotator cuff repair and acromioplasty versus rotator cuff repair alone, and rotator cuff repair and subacromial decompression versus subacromial decompression alone. Major outcomes were mean pain, shoulder function, quality of life, participant-rated global assessment of treatment success, adverse events and serious adverse events. The primary endpoint for this review was one year.

DATA COLLECTION AND ANALYSIS

We used standard methodologic procedures expected by Cochrane.

MAIN RESULTS

We included nine trials with 1007 participants. Three trials compared rotator cuff repair with subacromial decompression followed by exercises with exercise alone. These trials included 339 participants with full-thickness rotator cuff tears diagnosed with magnetic resonance imaging (MRI) or ultrasound examination. One of the three trials also provided up to three glucocorticoid injections in the exercise group. All surgery groups received tendon repair with subacromial decompression and the postoperative exercises were similar to the exercises provided for the non-operative groups. Five trials (526 participants) compared repair with acromioplasty versus repair alone; and one trial (142 participants) compared repair with subacromial decompression versus subacromial decompression alone. The mean age of trial participants ranged between 56 and 68 years, and females comprised 29% to 56% of the participants. Symptom duration varied from a mean of 10 months up to 28 months. Two trials excluded tears with traumatic onset of symptoms. One trial defined a minimum duration of symptoms of six months and required a trial of conservative therapy before inclusion. The trials included mainly repairable full-thickness supraspinatus tears, six trials specifically excluded tears involving the subscapularis tendon. All trials were at risk of bias for several criteria, most notably due to lack of participant and personnel blinding, but also for other reasons such as unclearly reported methods of random sequence generation or allocation concealment (six trials), incomplete outcome data (three trials), selective reporting (six trials), and other biases (six trials). Our main comparison was subacromial decompression versus non-operative treatment and results are reported for the 12 month follow up. At one year, moderate-certainty evidence (downgraded for bias) from 3 trials with 258 participants indicates that surgery probably provides little or no improvement in pain; mean pain (range 0 to 10, higher scores indicate more pain) was 1.6 points with non-operative treatment and 0.87 points better (0.43 better to 1.30 better) with surgery.. Mean function (zero to 100, higher score indicating better outcome) was 72 points with non-operative treatment and 6 points better (2.43 better to 9.54 better) with surgery (3 trials; 269 participants), low-certainty evidence (downgraded for bias and imprecision). Participant-rated global success rate was 873/1000 after non-operative treatment and 943/1000 after surgery corresponding to (risk ratio (RR) 1.08, 95% confidence interval (CI) 0.96 to 1.22; low-certainty evidence (downgraded for bias and imprecision). Health-related quality of life was 57.5 points (SF-36 mental component score, 0 to 100, higher score indicating better quality of life) with non-operative treatment and 1.3 points worse (4.5 worse to 1.9 better) with surgery (1 trial; 103 participants), low-certainty evidence (downgraded for bias and imprecision). We were unable to estimate the risk of adverse events and serious adverse events as only one event was reported across the trials (very low-certainty evidence; downgraded once due to bias and twice due to very serious imprecision).

AUTHORS' CONCLUSIONS

At the moment, we are uncertain whether rotator cuff repair surgery provides clinically meaningful benefits to people with symptomatic tears; it may provide little or no clinically important benefits with respect to pain, function, overall quality of life or participant-rated global assessment of treatment success when compared with non-operative treatment. Surgery may not improve shoulder pain or function compared with exercises, with or without glucocorticoid injections. The trials included have methodology concerns and none included a placebo control. They included participants with mostly small degenerative tears involving the supraspinatus tendon and the conclusions of this review may not be applicable to traumatic tears, large tears involving the subscapularis tendon or young people. Furthermore, the trials did not assess if surgery could prevent arthritic changes in long-term follow-up. Further well-designed trials in this area that include a placebo-surgery control group and long follow-up are needed to further increase certainty about the effects of surgery for rotator cuff tears.

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.

The Natural History of Full-Thickness Rotator Cuff Tears in Randomized Controlled Trials: A Systematic Review and Meta-analysis

BACKGROUND

Rotator cuff tears are the most common tendon injury in the adult population, resulting in substantial morbidity. The optimum management for these patients is not known.

PURPOSE

To assess the overall treatment response to all interventions in full-thickness rotator cuff tears among patients enrolled in randomized clinical trials.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

Randomized controlled trials (RCTs) were identified from a systematic search of Medline, Embase, CINHAL, and the Cochrane Central Register of Controlled Trials. Patients were aged ≥18 years with a full-thickness rotator cuff tear. The primary outcome measure was change in Constant shoulder score from baseline to 52 weeks. A meta-analysis to assess treatment response was calculated via the standardized mean change in scores.

RESULTS

A total of 57 RCTs were included. The pooled standardized mean change as compared with baseline was 1.42 (95% CI, 0.80-2.04) at 3 months, 2.73 (95% CI, 1.06-4.40) at 6 months, and 3.18 (95% CI, 1.64-4.71) at 12 months. Graphic plots of treatment response demonstrated a sustained improvement in outcomes in nonoperative trial arms and all operative subgroup arms.

CONCLUSION

Patients with full-thickness rotator cuff tears demonstrated a consistent pattern of improvement in Constant score with nonoperative and operative care. The natural history of patients with rotator cuff tears included in RCTs is to improve over time, whether treated operatively or nonoperatively.

Preoperative Pain Control in Arthroscopic Rotator Cuff Repair: Does It Matter?

Background

The purpose of this study was to clarify the importance of preoperative pain control using corticosteroid injections in patients with persistent rest pain (RP) before arthroscopic rotator cuff repair (ARCR).

Methods

A total of 360 patients (374 shoulders) who underwent primary ARCR and were followed up for at least 2 years were enrolled. After one-to-one propensity score matching, 266 patients (145 men and 128 women, 273 shoulders) were included in the study. Their mean age was 65.2 ± 7.7 years (range, 42 to 88 years) at the time of surgery. The patients were divided into three groups: those who required several intra-articular or subacromial bursa corticosteroid injections preoperatively for refractory RP (group A+), those in whom RP was resolved preoperatively (group A−), and those who had no RP and did not require any injections (group B). The incidence of postoperative RP and preoperative and final follow-up American Shoulder and Elbow Surgeons (ASES) scores were compared among the three groups.

Results

The incidence of postoperative RP was significantly higher in group A+ (35/91 cases, 38.5%) than in group A− (10/91, 11.0%) and group B (7/91, 7.7%, p < 0.001 for both). The preoperative ASES score was significantly lower in group A+ (33.2 ± 14.2) than in group A− (53.9 ± 11.9) and group B (62.3 ± 11.2, p < 0.001 for both), and it was significantly lower in group A− than in group B (p = 0.000). The final follow-up ASES score was significantly lower in group A+ (92.1 ± 8.4) than in group A− (97.6 ± 5.4) and group B (99.0 ± 2.5, p < 0.001 for both). There was no significant difference in the final follow-up ASES score between group A− and group B (p = 0.242).

Conclusions

Patients in whom preoperative RP could be resolved before surgery achieved postoperative outcomes comparable to those in patients who had no RP before surgery, whereas the outcomes in patients with refractory preoperative RP were inferior. The results suggest that preoperative pain control is important in patients undergoing ARCR.

The Timing of Injections Prior to Arthroscopic Rotator Cuff Repair Impacts the Risk of Surgical Site Infection

BACKGROUND

Corticosteroid injections are a common treatment for rotator cuff tears. Because of concerns of infection, a surgical procedure is often delayed following injections. The purpose of this investigation was to determine if there is a temporal relationship between corticosteroid injections and the risk of surgical site infection after arthroscopic rotator cuff repair. We hypothesized that the incidence of surgical site infection is higher in patients who received a preoperative injection and this relationship exists in a temporal manner as those patients receiving an injection closer to the operative date have a higher risk of infection.

METHODS

The PearlDiver database was reviewed for patients undergoing arthroscopic rotator cuff repair from 2007 to 2016. Patients were stratified into 2 cohorts: those undergoing arthroscopic rotator cuff repair within 1 year of injection (n = 12,060), and those undergoing arthroscopic rotator cuff repair without prior injection (n = 48,763). Patients with preoperative injections were further stratified by the duration in months that the injection was performed prior to the surgical procedure. Surgical site infection within 6 months of the surgical procedure was recorded. Statistical analysis included chi-square and multivariate binomial logistic regression analyses to identify risk factors for surgical site infection. Results were considered significant at p < 0.05.

RESULTS

There was no significant difference in the incidence of surgical site infection in patients receiving a shoulder injection at 0.7% compared with the control cohort at 0.8% (odds ratio [OR], 0.9 [95% confidence interval (CI), 0.7 to 1.1]; p = 0.2). However, patients receiving an injection within 1 month prior to operative management had a significantly higher rate of surgical site infection overall at 1.3% compared with the control group at 0.8% (OR, 1.7 [95% CI, 1.0 to 2.9]; p = 0.04). On multivariate analysis, male sex (OR, 1.7 [95% CI, 1.4 to 1.9]; p = 0.001), obesity (OR, 1.4 [95% CI, 1.2 to 1.6]; p < 0.001), diabetes (OR, 1.3 [95% CI, 1.1 to 1.5]; p < 0.001), smoking status (OR, 1.7 [95% CI, 1.4 to 1.9], p < 0.001), and preoperative corticosteroid injections within 1 month of the surgical procedure (OR, 2.1 [95% CI, 1.5 to 2.7]; p < 0.001) were independent risk factors for development of a surgical site infection.

CONCLUSIONS

Injections within 1 month of arthroscopic rotator cuff repair significantly increases the risk of surgical site infection. However, there is no increased risk of infection if the surgical procedure is delayed by 1 month following an injection.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Efficacy of suprascapular nerve block compared with subacromial injection: a randomized controlled trial in patients with rotator cuff tears

HYPOTHESIS

We aimed to compare the clinical efficacy of a suprascapular nerve block (SSNB) versus subacromial injection (SA) for outpatient treatment of patients with symptomatic rotator cuff tears in a double-blinded, randomized controlled trial using sealed-envelope randomization.

METHODS

A total of 42 participants with symptomatic partial- and full-thickness rotator cuff tears quantified by ultrasound or magnetic resonance imaging received either an ultrasound-guided SSNB or SA. The primary outcome measure was shoulder function measured by the modified Constant-Murley (CM) score and the secondary outcome was the pain score measured by a visual analog scale at 2, 6, and 12 weeks after injection.

RESULTS

We analyzed 43 shoulders (27 in male patients, 62.2%). The mean age was 65.2 years (standard deviation [SD], 11.9 years). Of the shoulders, 22 (51.2%) underwent SAs and 21 (48.8%) underwent SSNBs. Continuous variables were analyzed by an independent t test (2 tailed), and nominal data were analyzed by the Fisher exact test (1 sided). At 6 weeks, the mean change from the baseline CM score was significantly higher in the SSNB group than in the SA group (14.3 [SD, 18.1] vs 3.0 [SD, 12.8]; P = .048). At 12 weeks' follow-up, the SSNB group had a significantly higher CM score than the SA group (57.6 [SD, 10] vs 44.6 [SD, 16]; P = .023) and greater improvement from the baseline CM score (23.4 [SD, 17.5] vs 7.8 [SD, 16.5]; P = .014). At 12 weeks, the visual analog scale score was significantly better in the SSNB group than in the SA cohort (9.9 [SD, 3.3] vs 7.3 [SD, 4.3]; P = .03).

CONCLUSIONS

This study demonstrates that an SSNB resulted in better pain and functional results than an SA at 6 and 12 weeks for symptomatic rotator cuff tears.

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.

Subacromial decompression surgery for rotator cuff disease

BACKGROUND

Surgery for rotator cuff disease is usually used after non-operative interventions have failed, although our Cochrane Review, first published in 2007, found that there was uncertain clinical benefit following subacromial decompression surgery.

OBJECTIVES

To synthesise the available evidence of the benefits and harms of subacromial decompression surgery compared with placebo, no intervention or non-surgical interventions in people with rotator cuff disease (excluding full thickness rotator cuff tears).

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, Clinicaltrials.gov and WHO ICRTP registry from 2006 until 22 October 2018, unrestricted by language.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials (RCTs) of adults with rotator cuff disease (excluding full-thickness tears), that compared subacromial decompression surgery with placebo, no treatment, or any other non-surgical interventions. As it is least prone to bias, subacromial decompression compared with placebo was the primary comparison. Other comparisons were subacromial decompression versus exercises or non-operative treatment. Major outcomes were mean pain scores, shoulder function, quality of life, participant global assessment of success, adverse events and serious adverse events. The primary endpoint for this review was one year. For serious adverse events, we also included data from prospective cohort studies designed to record harms that evaluated subacromial decompression surgery or shoulder arthroscopy.

DATA COLLECTION AND ANALYSIS

We used standard methodologic procedures expected by Cochrane.

MAIN RESULTS

We included eight trials, with a total of 1062 randomised participants with rotator cuff disease, all with subacromial impingement. Two trials (506 participants) compared arthroscopic subacromial decompression with arthroscopy only (placebo surgery), with all groups receiving postoperative exercises. These trials included a third treatment group: no treatment (active monitoring) in one and exercises in the other. Six trials (556 participants) compared arthroscopic subacromial decompression followed by exercises with exercises alone. Two of these trials included a third arm: sham laser in one and open subacromial decompression in the other.Trial size varied from 42 to 313 participants. Participant mean age ranged between 42 and 65 years. Only two trials reported mean symptom duration (18 to 22 months in one trial and 30 to 31 months in the other), two did not report duration and four reported it categorically.Both placebo-controlled trials were at low risk of bias for the comparison of surgery versus placebo surgery. The other trials were at high risk of bias for several criteria, most notably at risk of performance or detection bias due to lack of participant and personnel blinding. We have restricted the reporting of results of benefits in the Abstract to the placebo-controlled trials.Compared with placebo, high-certainty evidence indicates that subacromial decompression provides no improvement in pain, shoulder function, or health-related quality of life up to one year, and probably no improvement in global success (moderate-certainty evidence, downgraded due to imprecision).At one year, mean pain (on a scale zero to 10, higher scores indicate more pain), was 2.9 points after placebo surgery and 0.26 better (0.84 better to 0.33 worse), after subacromial decompression (284 participants), an absolute difference of 3% (8% better to 3% worse), and relative difference of 4% (12% better to 5% worse). At one year, mean function (on a scale 0 to 100, higher score indicating better outcome), was 69 points after placebo surgery and 2.8 better (1.4 worse to 6.9 better), after surgery (274 participants), an absolute difference of 3% (7% better to 1% worse), and relative difference of 9% (22% better to 4% worse). Global success rate was 97/148 (or 655 per 1000), after placebo and 101/142 (or 708 per 1000) after surgery corresponding to RR 1.08 (95% CI 0.93 to 1.27). Health-related quality of life was 0.73 units (European Quality of Life EQ-5D, -0.59 to 1, higher score indicating better quality of life), after placebo and 0.03 units worse (0.011 units worse to 0.06 units better), after subacromial decompression (285 participants), an absolute difference of 1.3% (5% worse to 2.5% better), and relative difference of 4% (15% worse to 7% better).Adverse events including frozen shoulder or transient minor complications of surgery were reported in approximately 3% of participants across treatment groups in two randomised controlled trials, but due to low event rates we are uncertain if the risks differ between groups: 5/165 (37 per 1000) reported adverse events with subacromial decompression and 9/241 (34 per 1000) with placebo or non-operative treatment, RR 0.91 (95% CI 0.31 to 2.65) (moderate-certainty evidence, downgraded due to imprecision). The trials did not report serious adverse events.Based upon moderate-certainty evidence from two observational trials from the same prospective surgery registry, which also included other shoulder arthroscopic procedures (downgraded for indirectness), the incidence proportion of serious adverse events within 30 days following surgery was 0.5% (0.4% to 0.7%; data collected 2006 to 2011), or 0.6% (0.5 % to 0.7%; data collected 2011 to 2013). Serious adverse events such as deep infection, pulmonary embolism, nerve injury, and death have been observed in participants following shoulder surgery.

AUTHORS' CONCLUSIONS

The data in this review do not support the use of subacromial decompression in the treatment of rotator cuff disease manifest as painful shoulder impingement. High-certainty evidence shows that subacromial decompression does not provide clinically important benefits over placebo in pain, function or health-related quality of life. Including results from open-label trials (with high risk of bias) did not change the estimates considerably. Due to imprecision, we downgraded the certainty of the evidence to moderate for global assessment of treatment success; there was probably no clinically important benefit in this outcome either compared with placebo, exercises or non-operative treatment.Adverse event rates were low, 3% or less across treatment groups in the trials, which is consistent with adverse event rates reported in the two observational studies. Although precise estimates are unknown, the risk of serious adverse events is likely less than 1%.

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.

Differing efficacies of autologous platelet-rich plasma treatment in reducing pain following rotator-cuff injury in a single patient

Rotator-cuff tears (RCTs) are typically associated with chronic pain. The most common treatment for reducing pain is the injection of cortisone into the injury site. An alternative and increasingly used technique is the injection of autologous platelet-rich plasma (PRP). A limitation of cortisone is its pain relief is short-lived, while PRP has the limitation of providing pain relief to only about 50% of patients, making its efficacy questioned, although when it is effective, its efficacy is longer than cortisone. Little is known about what accounts for these limitations. This paper presents results from a patient with RCTs causing excruciating pain who received an injection of PRP into that shoulder resulting in complete pain elimination that was ongoing at 2 years and 2 months. When 7-month severe posttrauma pain associated with the RCT developed in the contralateral shoulder, PRP prepared the same way and injected by the same person who performed the first injection provided no pain relief. However, a subsequent single cortisone injection resulted in complete pain elimination, which was ongoing at >15 months. These observations indicate that PRP can have inconsistent effects in reducing pain, not only between patients but also within the same patient. Further, although the pain relief induced by cortisone is normally not long-lasting, when given following a PRP injection, it can induce complete pain relief lasting >15 months. This paper discusses possible reasons for the variability in PRP efficacy on pain relief and addresses the possibility that when administered together, PRP and cortisone may act in a complementary manner, leading to significantly greater and longer-lasting pain relief.

Conservative treatment of rotator cuff tear in older patients: a role for the cycloergometer? A randomized study

BACKGROUND

To date, there are no published data on the use of devices in the management of rotator cuff tear (RCT).

AIM

The aim of this study was to evaluate the effect of supervised arm cycloergometer training on pain during activities and shoulder functionality in patients with symptomatic full-thickness RCT.

DESIGN

This is a prospective randomized controlled pilot study.

SETTING

Outpatients of our Rehabilitation Unit.

POPULATION

In this pilot study, 40 elderly outpatients (>70 years) with RCT were randomized to two groups: cycloergometer (CYC) vs. control patients.

METHODS

All patients underwent a common outpatient rehabilitation exercise program consisting of ten 30-min sessions (5 sessions/week). At discharge, CYC patients received 15-min training with an arm cycloergometer and were invited to use the cycloergometer at home 20 min/twice a day. Control patients were invited to continue the standard exercises. During the 6-month study period CYC patients, but not control patients, received educational reinforcement monthly from the nurse of the telemedicine service. Outcomes assessed, between admission (T0) and 6-month follow-up (T6), were: pre to postpain during activities, active and passive ROMsum, ROM-painsum, revised Constant Total Score, and Health Assessment Questionnaire (HAQ).

RESULTS

At T6, CYC patients showed a significant improvement in all outcome measures with respect to T0 (all: P<0.001). CYC patients showed also significant improvement in passive forward elevation, abduction, and external rotation of shoulder, as well as in active ROMsum and ROM-painsum in all single shoulder movements, and significant improvement in the HAQ items: dressing/grooming, eating, hygiene, reach, and common daily activities. At T6 the CYC group had lower pain during activities (P<0.01) and higher revised constant total score (P<0.01), ROM-painsum (P<0.05) and active ROMsum (P<0.05) than control patients. Home cycloergometer use was inversely associated to pain during activities (P<0.01) and revised Constant Total Score (P<0.01) at T6.

CONCLUSIONS

A short program of shoulder passive exercises and cuff strengthening exercises followed by regular use of the cycloergometer for 6 months at home can reduce pain and improve shoulder functionality in RCT patients.

CLINICAL REHABILITATION IMPACT

Our findings indicate that the cycloergometer may be useful in patients with RCT when regularly used at home and suggest use of this mechanical device in rehabilitation programs for these patients.

Non-Operative Management of Rotator Cuff Tears

Background:

The role of nonoperative management for rotator cuff tears remains a matter of debate. Clinical results reported in the literature mainly consist of level IV studies, oftentimes combining a mixed bag of tear sizes and configurations, and are contradictory to some extent.

Methods:

A selective literature search was performed and personal surgical experiences are reported.

Results:

Most studies show an overall success rate of around 75% for nonoperative treatment. However, the majority of studies also present a progression of tear size and fatty muscle infiltration over time, with however debatable clinical relevance for the patient. Suggested factors associated with progression of a rotator cuff tear are an age of 60 years or older, full-thickness tears, and fatty infiltration of the rotator cuff muscles at the time of initial diagnosis.

Conclusion:

Non-operative management is indicated for patients with lower functional demands and moderate symptoms, and/or of course for those refusing to have surgery. Close routinely monitoring regarding development of tear size should be performed, especially in patients that remain symptomatic during nonoperative treatment. To ensure judicious patient counseling, it has to be taken into account that 1) tears that are initially graded as reparable may become irreparable over time, and 2) results after secondary surgical therapy after failed nonoperative treatment are usually reported to be inferior to those who underwent primary tendon repair.

Influence of Hyperlipidemia on the Treatment of Supraspinatus Tendinopathy With or Without Tear

Objective

To investigate the influence of hyperlipidemia on the treatment of supraspinatus tendinopathy, with or without tear.

Methods

We retrospectively reviewed the data of patients with shoulder pain and patients with supraspinatus tendinopathy, with or without tear, were included in the study. Exclusion criteria were prior shoulder surgery, prior steroid injection, neurological diseases that could lead to shoulder pain, and use of lipid-lowering medication. According to the serum lipid profiles, patients were assigned to either the hyperlipidemia or non-hyperlipidemia group. By analyzing the numeric rating scale (NRS) before treatment, and at 2 weeks and 8 weeks after treatment, we compared the difference in treatment effect between the two groups.

Results

No significant baseline difference was found among the two groups for age, gender, body mass index, duration of pain, side of pain, range of motion of affected shoulder, or physical examination. On the repeated-measures analysis of variance, NRS scores significantly decreased with time for both groups (p<0.001). When analyzing the effect of time between the subjects factor, there was significant difference in the treatment effect between the two groups (p<0.001), namely NRS was less decreased in the hyperlipidemia group.

Conclusion

We found that hyperlipidemia may be an adversely affecting factor in the treatment of supraspinatus tendinopathy with or without tear.

Efficacy of hyaluronic acid or steroid injections for the treatment of a rat model of rotator cuff injury

This study evaluated dorsal root ganglia from C3-C7, analyzed gait, and compared the expression of calcitonin gene-related peptide (CGRP) which was a marker of inflammatory pain in a rat rotator cuff tear model in which the supraspinatus and infraspinatus tendons were detached; comparisons were made to a sham group in which only the tendons were exposed. Fluorogold was injected into the glenohumeral joint 21 days after surgery in both groups, and saline, steroids, or hyaluronic acid was injected into the glenohumeral joint in the rotator cuff tear group 26 days after surgery. The proportions of CGRP-immunoreactive neurons were higher and the gait parameters were impaired in the rotator cuff tear group compared to in the sham group. However, the CGRP expression was reduced and the gait was improved with steroid or hyaluronic acid injection compared to saline, suggesting that both hyaluronic acid and steroid injections suppressed of inflammation which thought to be provided pain relief. While there were no significant differences, the suppression of CGRP expression and the improved gait after hyaluronic acid and steroid injections suggested that both methods were effective for rat rotator cuff tear model.

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.

Tendon and ligament regeneration and repair: clinical relevance and developmental paradigm

As dense connective tissues connecting bone to muscle and bone to bone, respectively, tendon and ligament (T/L) arise from the somitic mesoderm, originating in a recently discovered somitic compartment, the syndetome. Inductive signals from the adjacent sclerotome and myotome upregulate expression of Scleraxis, a key transcription factor for tenogenic and ligamentogenic differentiation. Understanding T/L development is critical to establishing a knowledge base for improving the healing and repair of T/L injuries, a high-burden disease due to the intrinsically poor natural healing response. Current treatment of the three most common tendon injuries-tearing of the rotator cuff of the shoulder, flexor tendon of the hand, and Achilles tendon-include mostly surgical repair and/or conservative approaches, including biophysical modalities such as rehabilitation and cryotherapy. Unfortunately, the fibrovascular scar formed during healing possesses inferior mechanical and biochemical properties, resulting in compromised tissue functionality. Regenerative approaches have sought to augment the injured tissue with cells, scaffolds, bioactive agents, and mechanical stimulation to improve the natural healing response. The key challenges in restoring full T/L function following injury include optimal combination of these biological agents as well as their delivery to the injury site. A greater understanding of the molecular mechanisms involved in T/L development and natural healing, coupled with the capability of producing complex biomaterials to deliver multiple biofactors with high spatiotemporal resolution and specificity, should lead to regenerative procedures that more closely recapitulate T/L morphogenesis, thereby offering future patients the prospect of T/L regeneration, as opposed to simple tissue repair.

Corticosteroids injection in rotator cuff tears in elderly patient: pain outcome prediction

AIM

The aim of this prospective study was to evaluate the effect of corticosteroids intra-articular injections on pain in patients with rotator cuff tear (RCT), and to identify predictors for pain outcomes.

METHODS

A total of 60 patients with RCT were enrolled. All patients underwent rehabilitation; 20 patients received a single intra-articular injection of 40 mg triamcinolone acetonide and 20 patients had a repeat injection at a 21-day interval. Backward stepwise regression analysis was used to predict effectiveness and improvement of pain. The independent variables were age, sex, symptom duration, tear size, passive range of motion (ROM), active ROM, non-steroidal anti-inflammatory drugs request, pain at rest, number of triamcinolone injections and severity of osteoarthritis at admission.

RESULTS

At 3 and 6 months, patients who received triamcinolone had higher effectiveness and improvement in pain during activities and pain at night than those of control group. At the 3-month interval post-therapy, active ROM was the only predictor for effectiveness in pain during activity, effectiveness in pain at night and improvement in pain at night. Six months after therapy, active ROM was a predictor for improvement in pain at night. Age was a predictor for effectiveness in pain at night, whereas tear size of RCT was a predictor for effectiveness and improvement in pain during activity.

CONCLUSIONS

Corticosteroids can relieve pain in RCT. Active ROM is the most important predictor of pain outcomes. This finding can be useful to physicians when deciding on the type of patients who might best benefit from intra-articular injections of corticosteroids.

Fortalecimento dos estabilizadores da cintura escapular na dor no ombro: revisão sistemática

INTRODUÇÃO: O controle e a ativação dos músculos estabilizadores são importantes para evitar a dor no ombro; dessa forma, o fortalecimento desses músculos pode auxiliar na redução e prevenção da dor no ombro. OBJETIVO: Revisar sistematicamente a literatura sobre o efeito do fortalecimento da musculatura estabilizadora da cintura escapular na redução da dor não diagnosticada no ombro. MATERIAIS E MÉTODOS: Selecionaram-se ensaios clínicos aleatórios publicados nas bases de dados PubMed, PEDro e Cochrane Library que investigaram o efeito do fortalecimento da musculatura estabilizadora da cintura escapular na dor, função, amplitude de movimento e força muscular de sujeitos adultos (≥ 21 anos) com dor no ombro. A Escala PEDro foi utilizada para determinar a qualidade metodológica dos estudos. RESULTADOS: Após seleção, encontraram-se 489 artigos; destes, cinco artigos corresponderam aos critérios de elegibilidade. Os cinco estudos analisavam o efeito do fortalecimento da musculatura estabilizadora associado a alongamento e outras formas de tratamento. Todos os estudos observaram redução da dor e melhora da função após o fortalecimento associado ao alongamento. A ADM e a força parecem melhorar após o fortalecimento associado ao alongamento. Entretanto, a qualidade metodológica e o número reduzido de estudos para cada desfecho não permitem inferir sobre a efetividade da intervenção. CONCLUSÃO: O fortalecimento dos estabilizadores associado ao alongamento diminui a dor e melhora a função do ombro. Futuros ensaios clínicos randomizados devem focar na melhor qualidade metodológica para verificar a efetividade do fortalecimento da musculatura estabilizadora da cintura escapular.

Interventional musculoskeletal US: an update on materials and methods

Pain is one of the most common causes of reduced productivity. The annual cost of health-related reductions in productivity has been estimated at approximately 225 billion dollars in the United States alone. Ultrasound-guided locoregional infiltration procedures have frequently been shown to offer economical, effective, lasting relief of pain. In-depth familiarity with the equipment (probes and needles) and techniques used to perform these procedures are fundamental for safe, effective treatment. In fact, depending on the characteristics of the patient and the clinical problem, the approach and technique may have to be modified to simplify the procedure and ensure better results. Up-to-date knowledge of the drugs used for these infiltrations (indications, how they are used) is equally important. Our aim is to provide an update on the techniques and materials used in interventional musculoskeletal ultrasonography based on a review of the most recent literature as well as on our personal experience.