Clinical Orthopaedics and Related Research®

, Volume 475, Issue 1, pp 232–243

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

  • Amin Mohamadi
  • Jimmy J. Chan
  • Femke M. A. P. Claessen
  • David Ring
  • Neal C. Chen
Meta-Analysis

DOI: 10.1007/s11999-016-5002-1

Cite this article as:
Mohamadi, A., Chan, J.J., Claessen, F.M.A.P. et al. Clin Orthop Relat Res (2017) 475: 232. doi:10.1007/s11999-016-5002-1

Abstract

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.

Supplementary material

11999_2016_5002_MOESM1_ESM.doc (66 kb)
Supplementary material 1 (DOC 65 kb)
11999_2016_5002_MOESM2_ESM.doc (26 kb)
Supplementary material 2 (DOC 26 kb)
11999_2016_5002_MOESM3_ESM.doc (49 kb)
Supplementary material 3 (DOC 49 kb)

Copyright information

© The Association of Bone and Joint Surgeons® 2016

Authors and Affiliations

  • Amin Mohamadi
    • 1
  • Jimmy J. Chan
    • 1
  • Femke M. A. P. Claessen
    • 1
  • David Ring
    • 2
  • Neal C. Chen
    • 1
  1. 1.Department of Orthopaedics, Hand and Upper Extremity ServiceMassachusetts General HospitalBostonUSA
  2. 2.Comprehensive Care, Dell Medical SchoolThe University of Texas at AustinAustinUSA