Not infrequently we'll see patients in whom the first or second injection helped, but from #3 on, there was no appreciable benefit. Occasionally we see shoulders that have had multiple injections and changes in the shoulder radiographs that are not typical of osteoarthritis. This is not intended to imply a cause/effect relationship.
Here's a recent example.
A very active young man sustained a hard fall on his shoulder. He received a series of intra articular injections as he documented for us here:
His current shoulder radiographs are shown here:
While this use of injections is common practice, we were struck by the cystic changes in the bone on both sides of the joint - changes that are not typical of post-traumatic arthritis in our experience. It is surely not possible to know if there was an association between these changes and the injections.
For comparison, the x-rays below show the more typical appearance of osteoarthritis.
Here are some quotes from the American Academy of Orthopaedic Surgeons 2013 guidelines (see this link) regarding the use of injections for arthritis of the knee:
Procedural Treatments: Recommendations 8-11
RECOMMENDATION 8
We are unable to recommend for or against the use of intraarticular (IA) corticosteroids for patients with symptomatic osteoarthritis of the knee.
Strength of Recommendation: Inconclusive
Description: Evidence from a single low quality study or conflicting findings that do not allow a recommendation for or against the intervention. An Inconclusive recommendation means that there is a lack of compelling evidence that has resulted in an unclear balance between benefits and potential harm.
Implications: Practitioners should feel little constraint in following a recommendation labeled as Inconclusive, exercise clinical judgment, and be alert for emerging evidence that clarifies or helps to determine the balance between benefits and potential harm. Patient preference should have a substantial influencing role.
RECOMMENDATION 9
We cannot recommend using hyaluronic acid for patients with symptomatic osteoarthritis of the knee.
Strength of Recommendation: Strong
Description: Evidence is based on two or more “High” strength studies with consistent findings for recommending for or against the intervention. A Strong recommendation means that the quality of the supportingevidenceishigh. Aharmsanalysisonthisrecommendationwasnotperformed.
Implications: Practitioners should follow a Strong recommendation unless a clear and compelling rationale for an alternative approach is present.
RECOMMENDATION 8
We are unable to recommend for or against the use of intraarticular (IA) corticosteroids for patients with symptomatic osteoarthritis of the knee.
Strength of Recommendation: Inconclusive
Description: Evidence from a single low quality study or conflicting findings that do not allow a recommendation for or against the intervention. An Inconclusive recommendation means that there is a lack of compelling evidence that has resulted in an unclear balance between benefits and potential harm.
Implications: Practitioners should feel little constraint in following a recommendation labeled as Inconclusive, exercise clinical judgment, and be alert for emerging evidence that clarifies or helps to determine the balance between benefits and potential harm. Patient preference should have a substantial influencing role.
RECOMMENDATION 9
We cannot recommend using hyaluronic acid for patients with symptomatic osteoarthritis of the knee.
Strength of Recommendation: Strong
Description: Evidence is based on two or more “High” strength studies with consistent findings for recommending for or against the intervention. A Strong recommendation means that the quality of the supportingevidenceishigh. Aharmsanalysisonthisrecommendationwasnotperformed.
Implications: Practitioners should follow a Strong recommendation unless a clear and compelling rationale for an alternative approach is present.
RECOMMENDATION 10
We are unable to recommend for or against growth factor injections and/or platelet rich plasma for patients with symptomatic osteoarthritis of the knee.
Strength of Recommendation: Inconclusive
Description: Evidence from a single low quality study or conflicting findings that do not allow a recommendation for or against the intervention. An Inconclusive recommendation means that there is a lack of compelling evidence that has resulted in an unclear balance between benefits and potential harm.
Implications: Practitioners should feel little constraint in following a recommendation labeled as Inconclusive, exercise clinical judgment, and be alert for emerging evidence that clarifies or helps to determine the balance between benefits and potential harm. Patient preference should have a substantial influencing role.
Here is an interesting recent post about platelet rich plasma (see this link).
The bottom line is that we do not know (1) how injections affect the natural history of shoulder arthritis or (2) what regimen of injections is likely to maximize safety and efficacy.
The patients we most commonly see in our office have advanced arthritis with virtually complete loss of the cartilage over the glenoid and humeral head. In such cases it seems unlikely that injections will change the subsequent course of the disease.
We are unable to recommend for or against growth factor injections and/or platelet rich plasma for patients with symptomatic osteoarthritis of the knee.
Strength of Recommendation: Inconclusive
Description: Evidence from a single low quality study or conflicting findings that do not allow a recommendation for or against the intervention. An Inconclusive recommendation means that there is a lack of compelling evidence that has resulted in an unclear balance between benefits and potential harm.
Implications: Practitioners should feel little constraint in following a recommendation labeled as Inconclusive, exercise clinical judgment, and be alert for emerging evidence that clarifies or helps to determine the balance between benefits and potential harm. Patient preference should have a substantial influencing role.
Here is an interesting recent post about platelet rich plasma (see this link).
The bottom line is that we do not know (1) how injections affect the natural history of shoulder arthritis or (2) what regimen of injections is likely to maximize safety and efficacy.
The patients we most commonly see in our office have advanced arthritis with virtually complete loss of the cartilage over the glenoid and humeral head. In such cases it seems unlikely that injections will change the subsequent course of the disease.
Consultation for those who live a distance away from Seattle.
Click here to see the new Shoulder Arthritis Book
Click here to see the new Rotator Cuff Book
To see the topics covered in this Blog, click here
Use the "Search" box to the right to find other topics of interest to you.
You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'
See from which cities our patients come.
See the countries from which our readers come on this post.
