Geriatric Rotator Cuff Tears – Intra-articular Shoulder Joint Steroid Injection For Pain Control

Recently, had an elderly but otherwise in good condition patient with tears of two of his shoulder rotator cuff tendons that he wished repaired. Was told by specialist – too far gone – and just learn to live with it. Now it looks like intra-articular steroid injection can almost cut pain in half for 3-4 months. A repeat shot at 3 weeks had no additional benefit so maybe it should be repeated at 3-4 months?

Geriatr Gerontol Int. 2013 Oct;13(4):993-1001.
Corticosteroids injection in rotator cuff tears in elderly patient: Pain outcome  prediction.
Gialanella B, Bertolinelli M.
http://www.ncbi.nlm.nih.gov/pubmed/24131759

  • Rotator cuff injuries might be painless or painful enough to affect sleep – prior articles have suggested this is more likely if more than one tendon is affected.
  • “Rotator cuff tendon surgery might be less successful in older adults and when RCT have retracted past the glenoid rim” – or if atrophic
  • there is concern that peritendonous injection of steroid may cause focal changes but not so much with intraarticular.
  • “Tillander et al. showed focal inflammation, necrosis and fragmentation of collagen bundles after five corticosteroid injections to the subacromial space of rats, but no pathological changes were observed after three injections.”- 0.09 mg crystalline triamcinolone each time.
    Tillander B, Franzén LE, Karlsson MH, Norlin R. Effect of steroid injections on the rotator cuff: an experimental study in rats. J Shoulder Elbow Surg 1999; 8: 271–274. http://www.sciencedirect.com/science/article/pii/S1058274699901416
  • “We chose intra-articular injection instead of subacromial bursa, despite the initial cause of the RCT pain being the subacromial space, because in the advanced stages of disease non-bursal causes might be the reason for shoulder pain.”

Method – 40 mg crystalline triamcinolone into shoulder by posterior approach; no local anaesthesia used.

Results: – pain at rest was minimal (1.7-1.9/10) so pain with acitivty was used.

  • Addition of a second shot at 3 weeks had no effect. This data was used in an earlier study:
    Effects of Corticosteroids Injection in Rotator Cuff Tears
    Bernardo Gialanella MD*, Paola Prometti MD
    Pain Medicine Volume 12, Issue 10, pages 1559–1565, October 2011
    http://onlinelibrary.wiley.com/doi/10.1111/j.1526-4637.2011.01238.x/abstract?deniedAccessCustomisedMessage=&userIsAuthenticated=false
  • Comment – injection into shoulder joint could reduce pains of rotator cuff tears in elderly by almost half  for 3-4 months. Repeat shot should wait 4 months or so. If you are a rat, 3 injections are safe, beyond that, I don’t know. I thought suprascapular nerve injection should help the pain but, the one case I did, said it made it worse….
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