HYALURONIC ACID INJECTIONS FOR ROTATOR CUFF PATHOLOGY

Rationale

Due to the heterogeneity of patient-reported outcomes and variability of study findings, the strength of the recommendation has been downgraded to limited.

Several high- and moderate- quality studies investigated the potential benefit of hyaluronic acid (HA) versus control. Hsieh et al (high quality, 2021; subacromial – subdeltoid injections) did not find any benefit with HA over saline injection in the short term except at 2 months (VAS for pain with activity). Cai et al (high quality, 2019; subacromial injections) found improved VAS (pain), ASES, and CM scores at one year follow-up. The Cai study utilized PRP + HA in one of their treatment arms. Clinical benefit from this admixture could not be definitively attributed to PRP or HA; as such, the authors’ conclusions should be carefully considered. Chou et al (high quality, 2010; subacromial bursa injections) found improved CM scores at one year with HA versus control group. Penning et al (high quality, 2012; subacromial injections) demonstrated improved “functional mobility test” scores at 3 months, but not at any further point in follow-up. 

When comparing CS versus HA, there are two high (Hsieh, 2021; Penning, 2012) and one moderate quality (Lim, 2014, glenohumeral joint injections) studies. Penning found CS to be superior to HA with regards to CM at short term follow-up (3 months). Hsieh et al treatment results varied depending on outcome measure and follow-up duration.

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.