Effect of Subacromial Injections of Hyaluronan on Different Grades of Rotator Cuff Lesion: A Prospective Study

Abstract

Rotator cuff lesions are quite common and in some cases Hyaluronic Acid (HA) can playa role in pain relief and in restoring functions. The aim of the study was to point out the correct indications for HA injection therapy through a prospective study: firstly defining the safety and efficacy of HA in the different grades of cuff tears, then evaluating the maintenance at 90 days, as secondary endpoint. A prospective, open-label uncontrolled study was developed. One hundred patients diagnosed with different rotator cuff lesions were divided into 4 grade-related groups based on a modified Neer's classification. A cycle of3 US-guided injections of medium-low weight HA was performed through the anterolateral way, one every two weeks. Follow-up was at 0, 15,30,45 and 90 days. VAS, Oxford-Shoulder-Score (OSS) and Constant-Murley were used for evaluations. In grade I and II, at day 45, a significant reduction of VAS and increase of Constant-Murley and OSS resulted. In grade IV VAS slowly decreased in the first 45 days, while OSS and Constant did not improve significantly. In grade III patients had no benefit from a clinical and subjective point of view. At ninety days the beneficial effect was still maintained in grades I, II and rv. Overall, the treatment showed a high tolerability profile. In conclusion, patients affected by bursitis or partial cuff tears benefit from HA, while in cuff arthropathy HA might only delay surgery or represent a palliative. In complete tears HA was not effective in pain relief or functional recovery.Shoulder pain is common, with a reported prevalence of 3-6.9% in the general population and 21% in those over 70 years of age (1), and shoulder disorders account for 1.2% of all visits to general practioners (2).Rotator cuff tendon tear is one of the most frequent painful condition in the shoulder and is the cause of degenerative changes in bone and muscles that modifies all the balance in the shoulder. It is in fact evolutive, leading to the so-called condition of cuff tear arthropathy or eccentric shoulder osteoarthritis. In such conditions, prior to any surgical indication, conservative treatments should be considered. Anti-inflammatory Drugs (NSAIDs), steroid oral administration or injections are still considered for an initial therapeutical approach (3, 4): however, they are affected by lots of adverse and side effects. In particular, intra-articular injections of steroids also expose patients to local adverse events: tendon atrophy, with fragmentation of collagen bundles and lost of the tensile properties (5). In these circumstances, hyaluronan (HA) (also referred to as hyaluronic acid or sodium hyaluronate) might have a novel role in the treatment of shoulder

Systematic Literature Review and Expert Opinion for the Use of Viscosupplementation with Hyaluronic Acid in Different Localizations of Osteoarthritis

“…In Shoulder localization, VS with HA 0.8% in 100 patients affected by cuff pathology (grades I–IV of Neer’s classification) induced reduction of pain measured by VAS at 30 days, as well as improvement of the OSS and Constant-Murley C-M score, the treatment being more effective in grades I and II. 29 Similar results were obtained by Gigante: 28 in patients with OA of grades I and II, HA 0.8% reduced the pain measured by VAS and improved the OSS and the C-M score starting from 15 and up to 90 days. VS proved to be less effective in grades III and IV.…”

“…In grade IV, benefits were recorded for the first 45 days, while OSS and Constant Murley scores did not show any improvement. Gigante 28 2013 Prospective, open-label, non-controlled. SHOULDER (PAIN).…”

“…For hip impingement, the pain was the most common inclusion criterion. 26 , 27 For shoulder localizations, Gigante 28 included patients aged between 35 and 70 years, affected by shoulder impingements of various degrees from bursitis to eccentric OA. In the study by Busilacchi, 29 the inclusion criteria allowed patients with cuff pathology of grades I–IV of Neer’s classification without indication of age.…”

“…For shoulder OA, in his study on pain, Gigante 28 excluded patients under 30 and over 80 years of age with shoulder instability, Superior Labral Tear from Anterior to Posterior (SLAP) lesions; rheumatoid arthritis, amyloidosis, chondrocalcinosis, gout, rheumatological diseases; shoulder trauma within the last year; adhesive capsulitis/calcific tendonitis, previous subacromial injections; diabetes, depression.…”

Comparison of single platelet-rich plasma injection with hyaluronic acid injection for partial-thickness rotator cuff tears

“…The subacromial bursa is crucial for normal shoulder function and subacromial gliding mechanism, as it contains extensive free nerve endings of nociceptive fibers, including A-delta and C-fibers. 28 Subacromial HA injection may inhibit the proinflammatory cytokines and decreased pain, 17,29 and subsequently improve shoulder function and ROM. Nevertheless, the numbers of injections varied from one to three times to five times, 18,19,25 and the injection sites varied from intra-articular to subacromial space among current studies.…”