The injection is actually a mixture of cortisone, a steroid similar to a chemical your own body makes, and lidocaine, a numbing medicine that may take your pain away within minutes of the injection. The injection is placed inside your shoulder, just on top of the rotator cuff. This injection may relieve your pain permanently. If not, the injection can be repeated. Numerous injections are to be avoided, as they may only mask a problem that needs more definitive treatment.
Arthroscopic Rotator Cuff Repair: If you continue to have pain or if you cannot get back to your normal activities, your doctor may offer you a surgery known as arthroscopic rotator cuff repair. This procedure uses specially designed instruments to sew the torn rotator cuff muscle back to the bone. Using a pencil-sized digital camera inserted into your shoulder for the duration of the surgery, the doctor views the action on a high definition flat screen monitor.
Large and massive rotator cuff tears involve at least two, but sometimes three or all four rotator cuff muscles, being torn from the bone. Repairing these tears is far more difficult, but a great repair can be accomplished arthroscopically. Sports medicine doctors specializing in shoulder arthroscopy can recognize the pattern of the tear and mobilize the edge of the torn muscle to complete an arthroscopic repair of large and massive tears.
Rehabilitation and physical therapy are critical for a successful outcome after an arthroscopic rotator cuff repair. The success rate from arthroscopic rotator cuff repair depends on what is being measured. Patient satisfaction is the most commonly reported outcome from arthroscopic rotator cuff repair. Patient satisfaction is measured with standardized tests based upon patient responses to questions regarding their pain levels following surgery and their ability to carry out daily household, work, and sporting activities.
Additional data is derived from physician measures of shoulder motion and rotator cuff strength. Find the Precision facility that is closest to you among our 10 locations throughout Maryland. Rotator Cuff Tear Learn more about our capabilities to treat rotator cuff pain. Quick Facts on Rotator Cuff Tears Rotator cuff tears can be painful and cause the limited function of the shoulder.
Our Sports Medicine doctors and orthopedic surgeons specializing in shoulder arthroscopy can recognize the pattern of the torn rotator cuff and help to mobilize torn muscle. Rotator cuff pain and injuries can be treated in a non-operative manner or via arthroscopic rotator cuff repair, depending on the severity of the injury and how early treatment can be delivered. Shoulder rehabilitation with our physical therapy teams is critical for a successful outcome after an arthroscopic rotator cuff repair.
What is a rotator cuff tear? Sari et al. The principal outcomes of interest included pain reduction, which was evaluated comparing the scales used in the studies VAS—Visual Analog Scale—scale [ 18 , 19 , 20 , 21 , 22 , 23 , 25 , 26 , 27 ] and Likert scale [ 24 ] and functional improvement of the shoulder. The results have been analyzed at the various stages of follow-up: short two to six weeks , medium 12 weeks and long term 24 weeks and more Table 4.
Nine studies analyzed the effects of corticosteroids [ 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 ]. Five of these compared corticosteroids with placebo [ 18 , 19 , 20 , 21 , 26 ], four of these with PRP [ 22 , 23 , 25 , 26 ] and two with prolotherapy [ 24 , 26 ].
Four studies analyzed the effects of PRP [ 22 , 23 , 25 , 26 ] comparing it with corticosteroids. Two studies analyzed the effects of prolotherapy [ 24 , 26 ]. Table 4. All the complications highlighted by Damjanov et al. The other studies did not report any other complications Table 6. The outcomes of the methodological quality assessment are shown in Table 1. An analysis of the literature has shown a progressive improvement in the quality of studies, evaluated through the use of the MINORS score.
From a graphic point of view, it is possible to notice a progressive increase in the trend line from to Figure 2. The most important finding of this study was that 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 seem to be superior only in terms of shoulder function.
Rotator cuff disorders are the most common cause of shoulder disability. However, management of rotator cuff problems remains controversial, mainly because of the remarkable variability of the clinical manifestations and insufficiency of information regarding the natural history of these disorders [ 28 , 29 ].
Recently, injection therapies including steroids, PRP, prolotherapy and sodium hyaluronate have been considered to treat those rotator cuff tendon problems. The indications are controversial and a complete agreement has not been reached so far by the various authors studying these methods [ 31 , 32 ]. Despite the advances in conservative treatment cases of tendinosis are still difficult to treat successfully in the long term [ 26 ]. Most of the studies did not include a detailed description of patient randomization methods; thus, we could not effectively evaluate for patient selection bias.
Using ROM as a surrogate outcome measure for functional assessment data should be viewed with caution, since the possible differences found could be due to inter- and intraoperator variability. The use of corticosteroids should be carefully evaluated given the high risk of muscle weakness, tendon rupture and collagen collapse [ 33 ].
PRP is a method recently developed due to the discovery of growth factors released by platelets, which have been shown to be effective in tissue repair. Prolotherapy injection is a technique that has been previously used treating other orthopedic diseases; the ease of application, the reduced cost and the reduction of the rehabilitation process make it advantageous [ 34 ].
This paper revealed that, with the aim of reducing pain, the effect of corticosteroid injection is stronger in the short and medium term compared to other injections although not statistically significant, whereas PRP provided better functional outcomes during the whole follow up period analyzed and more pain reduction in the long term Table 4. Therefore, for patients with partial rotator cuff tear, corticosteroid plays a role in the short term but not in long-term pain reduction.
By contrast, PRP may yield better outcomes according to shoulder functionality and long-term pain reduction. Only one study compared PRP and prolotherapy over the long term as regards pain control, highlighting the absence of significant differences [ 26 ].
Several systematic reviews have found the effectiveness of corticosteroids in the treatment of shoulder disorders [ 36 , 37 , 38 , 39 , 40 , 41 ]. Several authors agree with the concept that repeated corticosteroids injections at short intervals are dangerous with regard to tendon atrophy and reduction of connective tissue quality [ 42 , 43 ]. Despite the efficacy of prolotherapy on rotator cuff lesions [ 8 ], tendinopathies and fasciopathies of the lower limbs [ 44 ] reported in different papers, only two studies included in this review analyzed this technique; therefore more comparative trials need to be carried out to better evaluate this treatment.
The complications reported were described in only two of the studies analyzed [ 21 , 25 ]. Hong et Al. The remaining studies did not find or did not report any complications, although several studies in the literature have described tendon rupture events associated with the use of corticosteroids [ 45 ].
Because of the heterogeneity of the studies, a meta-analysis was not conducted. The available data does not allow to calculate the frequency and the optimal number of infiltrations to be carried out. Despite the PRP group constant score being significantly higher in short and long term follow up, the difference with the corticosteroid group was below the MCID minimal clinical importance difference.
Therefore, our results should be taken with caution, as the PRP may not be the appropriate treatment for every partial tear. It may be possible that a clinical difference would present with a longer follow-up period. An inter-reviewer agreement in assessing MINORS score of the studies included was not calculated, which is a limitation of the review process. The most relevant limitation of the present investigation is the low number of studies available on this topic. A further limitation is the difficulty to compare different outcomes, which was related to the differences in study design and in dose and medication used for the treatment.
Moreover, there is heterogeneity in diagnosis criteria among different trials. Many of the trials used clinical diagnosis for rotator cuff tendinopathy without image confirmations and it may be very difficult to differentiate a partial rupture from a total one. However, the present systematic review is the first piece of work carried out with the aim to evaluate the role of conservative treatment for partial thickness rotator cuff tears.
None of the techniques completely outperforms the others; a statistically significant improvement compared to baseline was found in all the surveys carried out for all the procedures. There are no statistically significant differences in terms of pain control between the treatment analyzed in short- and medium-term follow up.
In terms of shoulder function, the PRP was better in all follow-ups considered. No clear consensus can be found on the frequency of injections. The small number of studies analyzed regarding prolotherapy prevented our evaluating this treatment in depth. Future RCTs to better delineating the role of subacromial injection using different types of drugs in the management of partial rotator cuff tears are needed.
Conceptualization, F. All authors have read and agreed to the published version of the manuscript. National Center for Biotechnology Information , U. Journal List J Clin Med v. J Clin Med. Published online Dec Find articles by Edoardo Franceschetti. Find articles by Ferdinando De Dona. Find articles by Alessio Palumbo. Find articles by Michele Paciotti. Author information Article notes Copyright and License information Disclaimer.
Received Oct 31; Accepted Dec This article has been cited by other articles in PMC. Abstract 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. Keywords: rotator cuff tear, conservative treatment, injections, corticosteroids.
Experimental Section This systematic review was conducted in accordance with the PRISMA guidelines preferred reporting items of systematic reviews [ 16 ]. Open in a separate window. Figure 1. Literature Search A comprehensive, systematic literature search was performed in July Eligibility Criteria Only randomized or not controlled clinical trials published on peer-reviewed journals were included.
Table 1 Study details of the included articles. PRP vs. Prolotherapy vs. Data Extraction All the included studies were analyzed and following data were extracted and summarized in tables using Microsoft Excel version , Microsoft Corporation, Redmond, WA, USA : study type and year of publication, type of infiltration, number of patients, complications occurred, clinical scores reported.
Table 2 Main outcomes. Placebo Vecchio et al. Placebo Alvarez et al. Placebo Hong et al. Steroid vs. Placebo Von Wehren et al. PRP Shams et al. PRP Cole et al. Prolotherapy Damjanov et al. PRP Sari et al. Table 3 Summary: pain-function scores. Table 4 Clinical Outcomes. Table 5 Summary: ROM.
Placebo Study Quality To evaluate the methodological quality of the included studies, MINORS Methodological index for non-randomized studies tool for methodological quality assessment of nonrandomized studies score [ 17 ] was assessed for each of the studies. Statistical Analysis Statistical analysis of the data, for the purpose of a metanalysis, was not possible due to substantial heterogeneity in study design and populations.
Results A total of studies were found through the electronic searching engines. Interventions Four studies compared the usage of corticosteroids and placebo [ 18 , 19 , 20 , 21 ], three studies compared corticosteroids and PRP [ 22 , 23 , 26 ], one study compared corticosteroids with prolotherapy [ 24 ] and one study compared corticosteroids with all the other techniques mentioned above [ 26 ].
Outcome Measures The principal outcomes of interest included pain reduction, which was evaluated comparing the scales used in the studies VAS—Visual Analog Scale—scale [ 18 , 19 , 20 , 21 , 22 , 23 , 25 , 26 , 27 ] and Likert scale [ 24 ] and functional improvement of the shoulder. Outcomes Data The results have been analyzed at the various stages of follow-up: short two to six weeks , medium 12 weeks and long term 24 weeks and more Table 4. Corticosteroids Nine studies analyzed the effects of corticosteroids [ 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 ].
Prolotherapy Two studies analyzed the effects of prolotherapy [ 24 , 26 ]. Complications Hong et al. Table 6 Complications. Study Follow-Up wk No. Methodological Quality The outcomes of the methodological quality assessment are shown in Table 1. Discussion The most important finding of this study was that 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 seem to be superior only in terms of shoulder function.
Strengths and Limitations Despite the PRP group constant score being significantly higher in short and long term follow up, the difference with the corticosteroid group was below the MCID minimal clinical importance difference. Conclusions None of the techniques completely outperforms the others; a statistically significant improvement compared to baseline was found in all the surveys carried out for all the procedures.
Author Contributions Conceptualization, F. Funding This research received no external funding. Institutional Review Board Statement Not applicable. Informed Consent Statement Not applicable. Data Availability Statement Data derived from public domain resources. Conflicts of Interest The authors declare no conflict of interest. References 1. Lin K. Injection Therapies for Rotator Cuff Disease. North Am. Sher J.
Abnormal findings on magnetic resonance images of asymptomatic shoulders. Bone Joint Surg. Reilly P. Matthewson G. Kuhn J. Exercise in the treatment of rotator cuff impingement: A systematic review and a synthesized evidence-based rehabilitation protocol. Shoulder Elb. Desjardins-Charbonneau A. Sports Phys. Bertrand H. Lin M. Coombes B.
Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: A systematic review of randomised controlled trials. De Palma A. Surgery of the Shoulder. Keyes E. Observations on rupture of the supraspinatus tendon: Based upon a study of seventy-three cadavers. Lindblom K. On pathogenesis of ruptures of the tendon aponeurosis of the shoulder joint.
Acta Radiol. Uhthoff H. The pathogenesis of the rotator cuff tears; Proceedings of the 3rd International Conference on the Surgery of the Shoulder; Fukuoka, Japan. Pegreffi F. Conservative management of rotator cuff tear. Sports Med. Tillander B. Effect of steroid injections on the rotator cuff: An experimental study in rats. Moher D.
A cost-effectiveness analysis based on U. Hopewell S et al. Lancet Jul 31; Lancet Jul 31 Steroid injections provided short-term relief, and a single physical therapy session was as effective as more-intensive physical therapy. Comment The authors note that this is the largest randomized trial to date of exercise and injection for rotator cuff injuries. Citation s : Hopewell S et al. August 10, Boston, Massachusetts.
Palliative Care. Palliative Care, Lenox Hill Hospital. New York City, New York. Psychiatry - Epilepsy focused. Cleveland, Ohio. Durham, North Carolina. Study design: Cohort study; Level of evidence, 3. Methods: Patients who developed stiffness after arthroscopic rotator cuff repair were given a series of 3 intra-articular steroid injections every 4 weeks from 6 6-week group and 12 weeks week group postoperatively.
The control group had rotator cuff tears but neither stiffness nor injections. Repair integrity was assessed using magnetic resonance imaging at 6 months postoperatively. Results: Seventy-four of patients There were no significant differences in retear rates among the 6-week 5. However, both the 6- and week groups showed significantly lower KSS