CORTICOSTEROID INJECTIONS FOR ROTATOR CUFF TEARS
The use of a single injection of corticosteroids with local anesthetic can be considered for short-term improvement in both pain and function for patients with shoulder pain. In patients who cannot tolerate corticosteroids, injectable NSAIDs may be considered.
MODERATE RECOMMENDATION Rationale
Multiple high- and moderate-quality studies indicate that corticosteroid (CS) injections for patients with rotator cuff pathology are beneficial with regards to pain (VAS/SPS) level reduction (Moosmayer 2023; ElGendy 2023; Daghiani, 2023; Raeesi, 2022; Lee, 2022; Hopewell, 2021; Ekeberg, 2009; Alvarez, 2005; Kang, 2016; Abolhasani 2019; Hsieh, 2021; Carroll, 2018; Boonard, 2018; Sari, 2020; Babaei-Ghazani, 2019; Darrieutort-Lafitte, 2019; Liu, 2019; Louwerens, 2020; Holt, 2013; Eyigor, 2010; Penning, 2012; Atar, 2023; Hsieh, 2023; Hajivandi, 2021; Vergili, 2021; Apivatgaroon, 2023; Pasin, 2019; Ebadi, 2023; Dogan, 2021; Battaglia, 2017; Lee, 2017; Rabini, 2012; Lin, 2014).
Moosmayer et al (high quality study) demonstrated improved QuickDash and EQ-5D-5L outcomes at 1.5 months after corticosteroid injection, but not at 4, 8, 12, 24 months. When compared to physical therapy (PT), corticosteroid injections provided better QuickDash/SPADI/WORC scores (Daghiani, 2023). These studies indicate short-term benefit regarding pain level and function. Due to the heterogeneity of patient-reported outcomes and variability of study findings, the strength of the recommendation was downgraded to moderate.
Risks and Harms of Implementing this Recommendation
Corticosteroid injections in the setting of rotator cuff tears may be detrimental to the healing potential following rotator cuff repair. Considering that rotator cuff diagnoses are clinical, a single corticosteroid injection may be given to confirm the presence of a symptomatic rotator cuff tear but may adversely affect outcomes if performed in temporal proximity to surgical intervention.
Future Research
Further research is recommended to determine the role of corticosteroid injections in the various settings of rotator cuff pathology.
- Abolhasani, Hamed, Falsafi, Mani, Khafri, Soraya, Frydoni, Masoud Bahrami Comparison of efficacy of ketorolac, triamcinolone and betamethasone injections in the treatment of shoulder impingement syndrome. Journal of Evolution of Medical and Dental Sciences 2019; 26: 2050-2055
- Alvarez, C. M., Litchfield, R., Jackowski, D., Griffin, S., Kirkley, A. A prospective, double-blind, randomized clinical trial comparing subacromial injection of betamethasone and xylocaine to xylocaine alone in chronic rotator cuff tendinosis. American Journal of Sports Medicine 2005; 2: 255-62
- Apivatgaroon, A., Srimongkolpitak, S., Boonsun, P., Chernchujit, B., Sanguanjit, P. Efficacy of high-volume vs very low volume corticosteroid subacromial injection in subacromial impingement syndrome: a randomized controlled trial. Scientific Reports 2023; 1: 2174
- Atar, M. O., Korkmaz, N., Aslan, S. G., Tezen, O., Koylu, S. U., Demir, Y., Kesikburun, S. Comparison of ultrasound-guided subacromial corticosteroid and ozone (O2-O3) injections in the treatment of chronic rotator cuff tendinopathy: a randomized clinical trial. The Korean journal of pain 2023; 1: 128-136
- Babaei-Ghazani, A., Fadavi, H. R., Eftekharsadat, B., Ebadi, S., Ahadi, T., Ghazaei, F., Khabbaz, M. S. A Randomized Control Trial of Comparing Ultrasound-Guided Ozone (O2-O3) vs Corticosteroid Injection in Patients With Shoulder Impingement. American Journal of Physical Medicine & Rehabilitation 2019; 11: 1018-1025
- Battaglia, M., Guaraldi, F., Gori, D., Castiello, E., Arvat, E., Sudanese, A. Efficacy of triamcinolone acetate and methylprednisolone acetonide for intrabursal injection after ultrasound-guided percutaneous treatment in painful shoulder calcific tendonitis: a randomized controlled trial. Acta Radiologica 2017; 8: 964-970
- Boonard, M., Sumanont, S., Arirachakaran, A., Apiwatanakul, P., Boonrod, A., Kanchanatawan, W., Kongtharvonskul, J. Short-term outcomes of subacromial injection of combined corticosteroid with low-volume compared to high-volume local anesthetic for rotator cuff impingement syndrome: a randomized controlled non-inferiority trial. Eur J Orthop Surg Traumatol 2018; 6: 1079-1087
- Carroll, M. B., Motley, S. A., Smith, B., Ramsey, B. C., Baggett, A. S. Comparing Corticosteroid Preparation and Dose in the Improvement of Shoulder Function and Pain: A Randomized, Single-Blind Pilot Study. American Journal of Physical Medicine & Rehabilitation 2018; 6: 450-455
- Daghiani, M., Negahban, H., Ebrahimzadeh, M. H., Moradi, A., Kachooei, A. R., Raeesi, J., Divandari, A. The effectiveness of comprehensive physiotherapy compared with corticosteroid injection on pain, disability, treatment effectiveness, and quality of life in patients with subacromial pain syndrome: a parallel, single-blind, randomized controlled trial. Physiotherapy Theory & Practice 2023; 8: 1591-1605
- Darrieutort-Laffite, C., Varin, S., Coiffier, G., Albert, J. D., Planche, L., Maugars, Y., Cormier, G., Le Goff, B. Are corticosteroid injections needed after needling and lavage of calcific tendinitis? Randomised, double-blind, non-inferiority trial. Annals of the Rheumatic Diseases 2019; 6: 837-843
- Dogan, C., Ketenci, S., Uzuner, B., Sen, H. E., Bilgici, A., Alayli, G., Kuru, Ö Comparison of subacromial corticosteroid injection and physical therapy in patients with subacromial impingement syndrome: A prospective, randomized trial. Journal of Experimental and Clinical Medicine (Turkey) 2021; 4: 511-515
- Ebadi, S., Karimzad, Y., Aflakian, N., Forogh, B., Mansoori, K., Babaei-Ghazani, A. Extracorporeal shockwaves therapy versus corticosteroid injection for the treatment of non-calcific rotator cuff tendinopathies: a randomized trial. Current Orthopaedic Practice 2023; 4: 185-190
- Ekeberg, O. M., Bautz-Holter, E., Tveitå, E. K., Juel, N. G., Kvalheim, S., Brox, J. I. Subacromial ultrasound guided or systemic steroid injection for rotator cuff disease: randomised double blind study. BMJ 2009; 0: a3112
- ElGendy, M. H., Mazen, M. M., Saied, A. M., ElMeligie, M. M., Aneis, Y. Extracorporeal Shock Wave Therapy vs. Corticosteroid Local Injection in Shoulder Impingement Syndrome : A Three-Arm Randomized Controlled Trial. American Journal of Physical Medicine & Rehabilitation 2023; 6: 533-540
- Eyigor, C., Eyigor, S., Kivilcim Korkmaz, O. Are intra-articular corticosteroid injections better than conventional TENS in treatment of rotator cuff tendinitis in the short run? A randomized study. European journal of physical & rehabilitation medicine. 2010; 3: 315-24
- Hajivandi, S., Dachek, A., Salimi, A., Mamaghani, H. J., Mirghaderi, S. P., Dehghani, J., Borazjani, R., Babaniamansour, A., Sarallah, R., Javanshir, S., Salimi, M. Comparison of the Separate and Combined Effects of Physiotherapy Treatment and Corticosteroid Injection on the Range of Motion and Pain in Nontraumatic Rotator Cuff Tear: A Randomized Controlled Trial. Advances in Orthopaedics 2021; 0: 6789453
- Holt, T. A., Mant, D., Carr, A., Gwilym, S., Beard, D., Toms, C., Yu, L. M., Rees, J. Corticosteroid injection for shoulder pain: single-blind randomized pilot trial in primary care. Trials [Electronic Resource] 2013; 0: 425
- Hopewell, S., Keene, D. J., Heine, P., Marian, I. R., Dritsaki, M., Cureton, L., Dutton, S. J., Dakin, H., Carr, A., Hamilton, W., Hansen, Z., Jaggi, A., Littlewood, C., Barker, K., Gray, A., Lamb, S. E. Progressive exercise compared with best-practice advice, with or without corticosteroid injection, for rotator cuff disorders: the GRASP factorial RCT. Health Technology Assessment (Winchester, England) 2021; 48: 1-158
- Hsieh, L. F., Kuo, Y. C., Huang, Y. H., Liu, Y. F., Hsieh, T. L. Comparison of corticosteroid injection, physiotherapy and combined treatment for patients with chronic subacromial bursitis - A randomised controlled trial. Clinical Rehabilitation 2023; 9: 1189-1200
- Hsieh, L. F., Lin, Y. J., Hsu, W. C., Kuo, Y. C., Liu, Y. C., Chiang, Y. P., Wang, C. P. Comparison of the corticosteroid injection and hyaluronate in the treatment of chronic subacromial bursitis: A randomized controlled trial. Clinical Rehabilitation 2021; 9: 1305-1316
- Kang, Hua, Jiang, Hong, Chai, Dongdong, Lin, Yuan, Li, Qifang Comparison of the efficacy of subacromial injection with sodium bicarbonate versus corticosteroid in patients with chronic subacromial bursitis: a prospective, randomized and controlled study. International Journal of Clinical and Experimental Medicine 2016; 10: 18972-18980
- Lee, D. H., Yoon, S. H., Lee, M. Y., Kwack, K. S., Rah, U. W. Capsule-Preserving Hydrodilatation With Corticosteroid Versus Corticosteroid Injection Alone in Refractory Adhesive Capsulitis of Shoulder: A Randomized Controlled Trial. Archives of Physical Medicine & Rehabilitation 2017; 5: 815-821
- Lee, H. W., Kim, J. Y., Park, C. W., Haotian, B., Lee, G. W., Noh, K. C. Comparison of Extracorporeal Shock Wave Therapy and Ultrasound-Guided Shoulder Injection Therapy in Patients with Supraspinatus Tendinitis. Clinics in Orthopedic Surgery 2022; 4: 585-592
- Lim, T. K., Koh, K. H., Shon, M. S., Lee, S. W., Park, Y. E., Yoo, J. C. Intra-articular injection of hyaluronate versus corticosteroid in adhesive capsulitis. Orthopedics 2014; 10: e860-5
- Liu, C. T., Yang, T. F. Intra-substance steroid injection for full-thickness supraspinatus tendon rupture. BMC Musculoskeletal Disorders 2019; 1: 569
- Louwerens, J. K. G., Sierevelt, I. N., Kramer, E. T., Boonstra, R., van den Bekerom, M. P. J., van Royen, B. J., Eygendaal, D., van Noort, A. Comparing Ultrasound-Guided Needling Combined With a Subacromial Corticosteroid Injection Versus High-Energy Extracorporeal Shockwave Therapy for Calcific Tendinitis of the Rotator Cuff: A Randomized Controlled Trial. Arthroscopy 2020; 7: 1823-1833.e1
- Moosmayer, S., Ekeberg, O. M., Hallgren, H. B., Heier, I., Kvalheim, S., Juel, N. G., Blomquist, J., Pripp, A. H., Brox, J. I. Ultrasound guided lavage with corticosteroid injection versus sham lavage with and without corticosteroid injection for calcific tendinopathy of shoulder: randomised double blinded multi-arm study. BMJ 2023; 0: e076447
- Pasin, T., Ataoglu, S., Pasin, O., Ankarali, H. Comparison of the Effectiveness of Platelet-Rich Plasma, Corticosteroid, and Physical Therapy in Subacromial Impingement Syndrome. Archives of Rheumatology 2019; 3: 308-316
- Penning, L. I., de Bie, R. A., Walenkamp, G. H. The effectiveness of injections of hyaluronic acid or corticosteroid in patients with subacromial impingement: a three-arm randomised controlled trial. J Bone Joint Surg Br 2012; 9: 1246-52
- Rabini, A., Piazzini, D. B., Bertolini, C., Deriu, L., Saccomanno, M. F., Santagada, D. A., Sgadari, A., Bernabei, R., Fabbriciani, C., Marzetti, E., Milano, G. Effects of local microwave diathermy on shoulder pain and function in patients with rotator cuff tendinopathy in comparison to subacromial corticosteroid injections: a single-blind randomized trial. Journal of Orthopaedic & Sports Physical Therapy 2012; 4: 363-70
- Raeesi, J., Negahban, H., Kachooei, A. R., Moradi, A., Ebrahimzadeh, M. H., Daghiani, M. Comparing the effect of physiotherapy and physiotherapy plus corticosteroid injection on pain intensity, disability, quality of life, and treatment effectiveness in patients with Subacromial Pain Syndrome: a randomized controlled trial. Disability & Rehabilitation 2022; 0: 1-9
- Sari, A., Eroglu, A. Comparison of ultrasound-guided platelet-rich plasma, prolotherapy, and corticosteroid injections in rotator cuff lesions. Journal of Back & Musculoskeletal Rehabilitation 2020; 3: 387-396
- Vergili, O., Oktas, B., Canbeyli, I. D. Comparison of Kinesiotaping, Exercise and Subacromial Injection Treatments on Functionality and Life Quality in Shoulder Impingement Syndrome: A Randomized Controlled Study. Indian Journal of Orthopaedics 2021; 1: 195-202