Rotator Cuff Injury

[alophysio]

Hi,

Some quick results from Medline (tendon+steroid+shoulder) about tendon injuries from direct injection. Been an issue since the 70s.

Also, some evidence to suggest that injection with cortisone not any more effective than local anaesthetic.

If i had more time, i would check for more evidence - i am pretty sure there is evidence for 50% increased chance of tear in the Achilles after just ONE injection into the tendon...just not sure who did the research.

Enjoy the light reading below!

Alvarez, C. M., R. Litchfield, et al. (2005). "A prospective, double-blind, randomized clinical trial comparing subacromial injection of betamethasone and xylocaine to xylocaine alone in chronic rotator cuff tendinosis." Am J Sports Med 33(2): 255-62.
BACKGROUND: Rotator cuff tendinosis is a common problem with significant health and economic effects. Nonoperative management includes the widespread use of subacromial steroid injections despite the lack of evidence of its efficacy. HYPOTHESIS: A subacromial injection of betamethasone will be more effective than xylocaine alone in improving the quality of life, impingement sign, and range of motion in patients who have chronic rotator cuff tendinosis or partial rotator cuff tears. STUDY DESIGN: Randomized controlled clinical trial; Level of evidence, 1. METHODS: Patients with rotator cuff tendinosis or partial cuff tear with symptoms longer than 6 months, with failure of 6 weeks of physical therapy and 2 weeks of nonsteroidal anti-inflammatory drugs, who were older than 30 years of age, and who showed >50% improvement with the Neer impingement test were stratified for Workplace Safety and Insurance Board status and previous injection. Outcome measures--the Western Ontario Rotator Cuff Index; American Shoulder and Elbow Surgeons standardized form; Disabilities of the Arm, Shoulder and Hand; active forward elevation; active internal rotation; active external rotation; and the Neer impingement sign--were assessed at 2, 6, 12, and 24 weeks after injection. The injection into the subacromial space contained either 5 mL of 2% xylocaine alone or 4 mL of 2% xylocaine and 1 mL (6 mg) of betamethasone in an opaque syringe. RESULTS: In 58 patients (betamethasone group, n = 30; xylocaine group, n = 28), the authors found no statistically significant difference between the 2 treatment groups for all outcomes and time intervals. The scores for the Western Ontario Rotator Cuff Index at 3 months were xylocaine = 45.4% +/- 13% and betamethasone = 56.3% +/- 17% (P = .13). At 6 months, the scores were xylocaine = 51% +/- 32% and betamethasone = 59% +/- 26% (P = .38). All other outcomes showed similar values. As well, similar results were found for 2 and 6 weeks after injection. Both groups showed improvement from baseline in all outcomes. CONCLUSIONS: With the numbers available for this study, the authors found betamethasone to be no more effective in improving the quality of life, range of motion, or impingement sign than xylocaine alone in patients with chronic rotator cuff tendinosis for all follow-up time intervals evaluated.

Fisher, P. (2004). "Role of steroids in tendon rupture or disintegration known for decades." Arch Intern Med 164(6): 678.

Csizy, M. and B. Hintermann (2001). "[Rupture of the Achilles tendon after local steroid injection. Case reports and consequences for treatment]." Swiss Surg 7(4): 184-9.
It is known that Steroids increase the risk for tendon ruptures. Despite this local steroids are still used in the treatment of achilles tendinitis. Three cases are demonstrated. All of them show an unusual rupture mechanism. Intraoperatively necrotic tendon changes are seen. All patients receive an open tendon reconstruction with healthy, autologous material. Although there is a delayed healing in one case, all patients show favourable results one year postoperatively with return to full range activity levels and are able to participate in sports.

Kotnis, R. A., J. C. Halstead, et al. (1999). "Atraumatic bilateral Achilles tendon rupture: an association of systemic steroid treatment." J Accid Emerg Med 16(5): 378-9.
A case of bilateral Achilles tendon rupture associated with steroid use is reported. This case illustrates the importance of taking a thorough drug history in cases of tendon rupture. In lower limb tendon rupture all patients, especially those on steroids, should be warned of the increased risk of contralateral injury.

Smith, D. L. and S. M. Campbell (1992). "Painful shoulder syndromes: diagnosis and management." J Gen Intern Med 7(3): 328-39.
Painful shoulder conditions are common primary care problems. Providers should learn the topographical landmarks about the shoulder and understand shoulder mechanics. A careful clinical evaluation will usually provide a likely diagnosis. In unclear cases with marked pain, weakness, and reduced mobility, or with a suspected rotator cuff tear or rupture, arthrography or MRI will usually establish a diagnosis. Therapy of bursitis/tendinitis consists of a steroid injection into the inflamed subacromial area or a 14-day trial of an NSAID. Therapy of bicipital tendinitis, largely empiric because definitive studies are unavailable for any specific treatment, includes judicious peritendinous steroid injections and avoiding aggravating activities. In the management of patients with suspected tendon tears or rupture, primary care practitioners can confirm the diagnosis by ordering MRI or arthrography before referring these patients to an orthopedist for definitive surgical therapy. Optimal management of adhesive capsulitis remains unclear, but an intraarticular steroid injection appears beneficial at least in temporarily diminishing pain. Pendular motion exercising is also an integral part of therapy. Deleterious effects of peribursal or intraarticular steroid infiltration appear minimal; but injections into the tendon or frequent, repetitive injections are contraindicated. Each shoulder condition has a variable course, depending on the structure(s) and extent of involvement.

Watson, M. (1985). "Major ruptures of the rotator cuff. The results of surgical repair in 89 patients." J Bone Joint Surg Br 67(4): 618-24.
Major ruptures of the rotator cuff were repaired in 89 patients over a six-year period, using an approach through the split deltoid muscle and the bed of the excised outer centimetre of the clavicle. Review of these patients showed that poor results were associated with larger cuff defects, with more pre-operative steroid injections and with pre-operative weakness of the deltoid muscle. A randomised prospective study showed that repair followed by splinting in abduction gave no better results than repair followed by resting the arm at the side. Excision of the coraco-acromial ligament was associated with worse results than leaving its divided halves in situ. Follow-up showed that the results continued to improve for two years after operation; their quality was maintained in patients less than 60 years old, but in those over 60 there was deterioration with time.

Karpman, R. R., J. E. McComb, et al. (1980). "Tendon rupture following local steroid injection: report of four cases." Postgrad Med 68(1): 169-74.

Ford, L. T. and J. DeBender (1979). "Tendon rupture after local steroid injection." South Med J 72(7): 827-30.
Thirteen patients who developed 15 ruptured tendons subsequent to injection of a depository steroid in or about the tendons are described. Eight were treated surgically. Ruptures were encountered in three Achilles tendons, two supraspinati, one lateral epicondylar attachment at the elbow, eight tendons of the long head of the biceps at the shoulder, and one anterior tibial tendon. Measures designed to lessen this complication are described. In most cases triamcinolone hexacetonide was used as the depository steroid, mixed with procaine or lidocaine. Patients with this complication who were not treated surgically were the older patients who had ruptures of the tendon of the long head of the biceps.

Darlington, L. G. and E. N. Coomes (1977). "The effects of local steroid injection for supraspinatus tears." Rheumatol Rehabil 16(3): 172-9.