Saturday, April 2, 2011

Injections for shoulder arthritis

At the outset, I should state that I don't employ injections of the shoulder in my practice. Yet, for completeness, the reader should know that injections are used by others for one of two purposes. First, some physicians inject a local anesthetic into the joint in an attempt to confirm that the symptoms are coming from the shoulder joint rather than from other sources, such as a pinched nerve in the neck. In this application, the effect of the local anesthetic wears off soon afterwards, but the temporary relief of pain from an injection in the joint indicates that the pain is coming from the joint. Second, some physicians inject the shoulder in an attempt to provide some more lasting relief of pain. Two types of injections have been used: (1) steroids (like cortisone) and (2) viscosupplementation (like hyaluronic acid). For the interested reader, two reviews of these types of injections for osteoarthritis were published in 2006:

*Stitik, T. P., A. Kumar, et al. (2006). "Corticosteroid injections for osteoarthritis." Am J Phys Med Rehabil 85(11 Suppl): S51-65
*Stitik, T. P. and J. A. Levy (2006). "Viscosupplementation (biosupplementation) for osteoarthritis." Am J Phys Med Rehabil 85(11 Suppl): S32-50.

While these injections may provide symptomatic relief, a recent review of guidelines for the treatment of shoulder arthritis (Izquierdo, R., I. Voloshin, et al. "Treatment of glenohumeral osteoarthritis." J Am Acad Orthop Surg 18(6): 375-82.) failed to find substantial evidence in favor of their effectiveness. Similarly, a Cochrane review did not find evidence supporting the use of cortisone injections for shoulder pain (Buchbinder, R., S. Green, et al. (2003). "Corticosteroid injections for shoulder pain." Cochrane Database Syst Rev(1): CD004016.).

However, several relatively recent articles have provided some indication of the benefit of viscosupplementation for shoulder arthritis:

*Brander, V. A., A. Gomberawalla, et al. "Efficacy and safety of hylan G-F 20 for symptomatic glenohumeral osteoarthritis: a prospective, pilot study." PM R 2(4): 259-67.
*Noel, E., P. Hardy, et al. (2009). "Efficacy and safety of Hylan G-F 20 in shoulder osteoarthritis with an intact rotator cuff. Open-label prospective multicenter study." Joint Bone Spine 76(6): 670-3.
*Silverstein, E., R. Leger, et al. (2007). "The use of intra-articular hylan G-F 20 in the treatment of symptomatic osteoarthritis of the shoulder: a preliminary study." Am J Sports Med 35(6): 979-85.

Finally, it is important to note that in cases of shoulder joint infection, a high percentage appear to follow injections of the shoulder, so caution is advised:

*Rhee, Y. G., N. S. Cho, et al. (2008). "Injection-induced pyogenic arthritis of the shoulder joint." J Shoulder Elbow Surg 17(1): 63-7.
*Esenwein, S. A., T. Ambacher, et al. (2002). "[Septic arthritis of the shoulder following intra-articular injection therapy. Lethal course due to delayed initiation of therapy]." Unfallchirurg 105(10): 932-8.
*Leslie, B. M., J. M. Harris, 3rd, et al. (1989). "Septic arthritis of the shoulder in adults." J Bone Joint Surg Am 71(10): 1516-22.


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