NIHR DC Discover

NIHR Signal Corticosteroid injections provide only short term relief for rotator cuff disorders

Published on 5 October 2016

doi: 10.3310/signal-000312

A corticosteroid steroid injection into the shoulder provides some short-term pain relief for adults with rotator cuff disorders.

This review compared injection of corticosteroids (‘steroids’) with injection of local anaesthetic or placebo. The average improvement in pain relief at two months was calculated as moderate using standardised techniques. The effect wore off by three months.

Given the temporary benefits, it may be worth considering other treatments including physiotherapy alongside a steroid injection. Information given by an injecting physiotherapist, for example, regarding the expected duration of pain relief could also help manage the patient’s expectations for recovery in these painful conditions.

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Why was this study needed?

Shoulder disorders are common and affect about three in ten adults at any one time. Rotator cuff disorders are the most common cause of shoulder pain. The tendons in the shoulder can be vulnerable to injury or tear, getting trapped (impingement), or just gradual degeneration of the tendon as a normal part of aging. Giving a corticosteroid injection into the joint is one option to treat pain.

Despite the widespread use of corticosteroid injections, past trials have had mixed findings and their use continues to be debated. The last review on the topic was conducted in 2010, and since then four new trials have been published.

What did this study do?

This systematic review and meta-analysis identified 11 randomised controlled trials including 726 adults with rotator cuff disorders. One of the trials compared corticosteroid injection with placebo injection of salt water, and the remaining trials compared with injection of local anaesthetic. Three trials used repeat injections.

All trials assessed pain at one, two and three months after the injections using a 0 to 10 visual analogue scale (VAS), with 10 indicating severe pain and 0 indicating no pain.

The number needed to treat (NNT) was calculated as the number of adults who would need to have an injection in order for one to experience a decrease in their pain score to mild or less (3.4 or lower on the VAS).

The researchers excluded three trials considered low quality. There was also substantial variation in the interventions and the way the trails were undertaken and this might lessen the applicability of the results to usual UK practice.

What did it find?

  • Corticosteroid injections did not significantly reduce pain compared with control at the final three month assessment (Hedges’ g effect size 0.23, 95% confidence interval [CI] -0.09 to 0.56).
  • At one month, corticosteroid injections had a small to moderate effect on pain compared with the control (Hedges’ g 0.44, 95% CI 0.15 to 0.73). However, less than 1 in 1000 who received a corticosteroid injection would meet the definition of mild pain at this point, so it was not possible to calculate a NNT.
  • The largest effect on pain was seen at two months (Hedges’ g 0.52, 95% CI 0.27 to 0.78). At least five adults with rotator cuff tendinosis would need to be treated with corticosteroid injections for one person to experience only mild pain at two months.
  • Repeated corticosteroid injections were no more effective than giving a single corticosteroid injection at all assessment points up to three months following injection.

What does current guidance say on this issue?

There is no NICE guidance on use of corticosteroid injections for treating rotator cuff disorders.

2010 guidance from the American Academy of Orthopaedic Surgeons on the use of corticosteroids for rotator cuff tears is inconclusive due to a lack of compelling evidence. It suggests practitioners use individual judgement and consider future publications and patient preference in their decision making.

What are the implications?

Corticosteroid injections provide moderate pain relief for adults with rotator cuff disorders up to two months after injection. There is no evidence of any effect after this time.

Steroids are unlikely to affect the long-term progress of these disorders but they may provide some short term relief. Other treatments such as exercise and physiotherapy also show some benefit. The cause of rotator cuff disorder, severity and duration of pain varied among the participants in these trials. Therefore, it is unclear if corticosteroid injections could be of universal help. A tailored offering including other therapies remains a pragmatic approach for now, while alerting patients to the short lived benefit.

Citation and Funding

Mohamadi A, Chan JJ, Claessen FM, et al. Corticosteroid injections give small and transient pain relief in rotator cuff tendinosis: a meta-analysis. Clin Orthop Relat Res. 2016. [Epub ahead of print, 28 July 2016].

No funding information was provided for this study.

Bibliography

American Academy of Orthopaedic Surgeons. Clinical practice guideline on the diagnosis and treatment of osteochondritis dissecans. Rosemont (IL): American Academy of Orthopaedic Surgeons (AAOS); 2010.

NHS Choices. Shoulder pain. London: Department of Health; 2014.

Why was this study needed?

Shoulder disorders are common and affect about three in ten adults at any one time. Rotator cuff disorders are the most common cause of shoulder pain. The tendons in the shoulder can be vulnerable to injury or tear, getting trapped (impingement), or just gradual degeneration of the tendon as a normal part of aging. Giving a corticosteroid injection into the joint is one option to treat pain.

Despite the widespread use of corticosteroid injections, past trials have had mixed findings and their use continues to be debated. The last review on the topic was conducted in 2010, and since then four new trials have been published.

What did this study do?

This systematic review and meta-analysis identified 11 randomised controlled trials including 726 adults with rotator cuff disorders. One of the trials compared corticosteroid injection with placebo injection of salt water, and the remaining trials compared with injection of local anaesthetic. Three trials used repeat injections.

All trials assessed pain at one, two and three months after the injections using a 0 to 10 visual analogue scale (VAS), with 10 indicating severe pain and 0 indicating no pain.

The number needed to treat (NNT) was calculated as the number of adults who would need to have an injection in order for one to experience a decrease in their pain score to mild or less (3.4 or lower on the VAS).

The researchers excluded three trials considered low quality. There was also substantial variation in the interventions and the way the trails were undertaken and this might lessen the applicability of the results to usual UK practice.

What did it find?

  • Corticosteroid injections did not significantly reduce pain compared with control at the final three month assessment (Hedges’ g effect size 0.23, 95% confidence interval [CI] -0.09 to 0.56).
  • At one month, corticosteroid injections had a small to moderate effect on pain compared with the control (Hedges’ g 0.44, 95% CI 0.15 to 0.73). However, less than 1 in 1000 who received a corticosteroid injection would meet the definition of mild pain at this point, so it was not possible to calculate a NNT.
  • The largest effect on pain was seen at two months (Hedges’ g 0.52, 95% CI 0.27 to 0.78). At least five adults with rotator cuff tendinosis would need to be treated with corticosteroid injections for one person to experience only mild pain at two months.
  • Repeated corticosteroid injections were no more effective than giving a single corticosteroid injection at all assessment points up to three months following injection.

What does current guidance say on this issue?

There is no NICE guidance on use of corticosteroid injections for treating rotator cuff disorders.

2010 guidance from the American Academy of Orthopaedic Surgeons on the use of corticosteroids for rotator cuff tears is inconclusive due to a lack of compelling evidence. It suggests practitioners use individual judgement and consider future publications and patient preference in their decision making.

What are the implications?

Corticosteroid injections provide moderate pain relief for adults with rotator cuff disorders up to two months after injection. There is no evidence of any effect after this time.

Steroids are unlikely to affect the long-term progress of these disorders but they may provide some short term relief. Other treatments such as exercise and physiotherapy also show some benefit. The cause of rotator cuff disorder, severity and duration of pain varied among the participants in these trials. Therefore, it is unclear if corticosteroid injections could be of universal help. A tailored offering including other therapies remains a pragmatic approach for now, while alerting patients to the short lived benefit.

Citation and Funding

Mohamadi A, Chan JJ, Claessen FM, et al. Corticosteroid injections give small and transient pain relief in rotator cuff tendinosis: a meta-analysis. Clin Orthop Relat Res. 2016. [Epub ahead of print, 28 July 2016].

No funding information was provided for this study.

Bibliography

American Academy of Orthopaedic Surgeons. Clinical practice guideline on the diagnosis and treatment of osteochondritis dissecans. Rosemont (IL): American Academy of Orthopaedic Surgeons (AAOS); 2010.

NHS Choices. Shoulder pain. London: Department of Health; 2014.

Corticosteroid Injections Give Small and Transient Pain Relief in Rotator Cuff Tendinosis: A Meta-analysis

Published on 30 July 2016

Mohamadi, A.,Chan, J. J.,Claessen, F. M.,Ring, D.,Chen, N. C.

Clin Orthop Relat Res , 2016

BACKGROUND: The ability of injection of corticosteroids into the subacromial space to relieve pain ascribed to rotator cuff tendinosis is debated. The number of patients who have an injection before one gets relief beyond what a placebo provides is uncertain. QUESTIONS/PURPOSES: We asked: (1) Do corticosteroid injections reduce pain in patients with rotator cuff tendinosis 3 months after injection, and if so, what is the number needed to treat (NNT)? (2) Are multiple injections better than one single injection with respect to pain reduction at 3 months? METHODS: We systematically searched seven electronic databases for randomized controlled trials of corticosteroid injection for rotator cuff tendinosis compared with a placebo injection. Eligible studies had at least 10 adults and used pain intensity as an outcome measure. The Hedges's g as adjusted pooled standardized mean difference (SMD) (which expresses the size of the intervention effect in each study relative to the total variability observed among pooled studies) and NNT were calculated at assessment points less than 1 month, 1-2 months, and 2-3 months. The protocol of this study was registered at the international prospective register of systematic reviews. Eleven studies of 726 patients satisfied our criteria for data pooling. Three studies containing 292 patients used repeat injections. A random effects model was used owing to substantial heterogeneity among studies. The funnel plot indicated the possibility of some missing studies, but Orwin's fail-safe N and Duval and Tweedie's trim and fill suggested that missing studies would not significantly affect the results. RESULTS: Corticosteroid injection did not reduce pain intensity in adult patients with rotator cuff tendinosis more than a placebo injection at the 3-month assessment. A small transient pain relief occurred at the assessment between 4 and 8 weeks with a SMD of 0.52 (range, 0.27-0.78) (p < 0.001). At least five patients must be treated for one patient's pain to be transiently reduced to no more than mild. Multiple injections were not found to be more effective than a single injection at any time. CONCLUSIONS: Corticosteroid injections provide-at best-minimal transient pain relief in a small number of patients with rotator cuff tendinosis and cannot modify the natural course of the disease. Given the discomfort, cost, and potential to accelerate tendon degeneration associated with corticosteroids, they have limited appeal. Their wide use may be attributable to habit, underappreciation of the placebo effect, incentive to satisfy rather than discuss a patient's drive toward physical intervention, or for remuneration, rather than their utility. LEVEL OF EVIDENCE: Level I, therapeutic study.

Expert commentary

This systematic review of the use of corticosteroid injections for shoulder pain due to rotator cuff tendinopathy shows that injections provide no pain relief at three months after the injection. The authors report a small and short lived reduction in pain between one and two months after treatment and that multiple injections are no more beneficial than single injection. The widespread use of corticosteroid injections for shoulder pain is not supported by evidence.

Andrew Carr, Professor of Orthopaedic Surgery, University of Oxford