Limited evidence supports for the possible use of hyaluronic acid injections in the non-operative management of rotator cuff pathology with no tears.

Management of Rotator Cuff Injuries
Endorsed by: AANA, ASES, AOSSM, ASSET, APTA
Limited Evidence LIMITED EVIDENCE
Rationale
One high quality study (Penning, L. I. F., 2012) compared subacromial corticosteroid injections with hyaluronic acid injections or lidocaine (placebo) injections in patients with subacromial impingement. There was no convincing benefit detected from hyaluronic acid injections compared with corticosteroid or placebo injections for up to 26 weeks.

One moderate quality study (Moghtaderi, A. 2013) compared ultrasound guided subacromial sodium hyaluronate injection saline in patients with impingement syndrome without complete tear of rotator cuff at 12 weeks. Both injections showed improvement, but sodium hyaluronate showed better results.

One moderate quality study (Byun, S. D. 2011) sono-guided subacromial bursa injection of steroid injection followed by sodium hyaluronate injection once a week for 3 weeks with a sono-guided subacromial bursa steroid injection once a week for 3 weeks for patients with subacromial bursitis, partial or complete rotator cuff tear. The study concluded that Subacromial bursa injection of hyaluronate with steroid in patients with peri-articular shoulder disorders has additive effects on functional improvement.

One moderate quality study (Ozgen, M.; 2012) compared short- and long-term effect of intraarticular sodium hyaluronate injection in patients with supraspinatus tendinitis (ST) with conventional physiotherapy methods. Both groups received home exercise programs. The study concluded that physical therapy modalities and SH application had similar effects in short- and long term for painful ST.

One moderate quality study (Meloni, F 2008) examined the effect of ultrasound guided periarticular injection of hyaluronate into shoulders with supraspinatus tendinosis compared to saline injections. Both were done weekly for a total of 5 injections. At 12 months follow up, sodium hyaluronate had better clinical outcomes.

Despite the medium-high quality of the above studies, the strength of the recommendation was downgraded to limited due to variability of study findings.

Risks and Harms of Implementing this Recommendation
There are no known risks to hyaluronic acid injections that are specific to shoulders or the rotator cuff.

Future Research
Further research may be conducted to further define the role of hyaluronic acid injections in rotator cuff pathology.
  1. Byun, S. D., Park, D. H., Choi, W. D., Lee, Z. I. Subacromial Bursa Injection of Hyaluronate with Steroid in Patients with Peri-articular Shoulder Disorders. 2011; 5: 664-72
  2. Meloni, F., Milia, F., Cavazzuti, M., Doria, C., Lisai, P., Profili, S., Meloni, G. B. Clinical evaluation of sodium hyaluronate in the treatment of patients with sopraspinatus tendinosis under echographic guide: experimental study of periarticular injections. European Journal of Radiology 2008; 1: 170-3
  3. Moghtaderi, A., Sajadiyeh, S., Khosrawi, S., Dehghan, F., Bateni, V. Effect of subacromial sodium hyaluronate injection on rotator cuff disease: A double-blind placebo-controlled clinical trial. Adv Biomed Res 2013; 0: 89
  4. Ozgen, M., Firat, S., Sarsan, A., Topuz, O., Ardic, F., Baydemir, C. Short- and long-term results of clinical effectiveness of sodium hyaluronate injection in supraspinatus tendinitis. Rheumatology International 2012; 1: 137-44
  5. Penning, L. I. F., De Bie, R. A., Walenkamp, G. H. I. M. The effectiveness of injections of hyaluronic acid or corticosteroid in patients with subacromial impingement: A three-arm randomised controlled trial. Journal of Bone and Joint Surgery - Series B 2012; 9: 1246-1252