Rotator Cuff Tendinopathy (RCT) is a progressive disorder of the shoulder which begins with acute tendonitis, and progresses to tendinosis (degenerative tearing). From here, RCT can progress into partial thickness tears, and eventually a full thickness rupture. Many factors contribute to the wear and tear of the Rotator Cuff. These include the natural aging process, poor blood flow, and altered biology. Also, both intrinsic and extrinsic factors combine to cause tissue break down. Some intrinsic factors are diabetes mellitus, obesity, smoking, and high cholesterol. Whereas, extrinsic factors may include a hooked acromion (bone in shoulder joint), mechanical overuse, dislocations and fractures.
With failed conservative treatment (physical therapy, over the counter pain control, etc.), most providers treat with corticosteroid injection for persistent shoulder pain. Unfortunately in current medical literature, the effectiveness of corticosteroids is under considerable question. In the short term (1-2 weeks), corticosteroids seem effective. However many negative side effects and counterproductive changes to the tendon occur. These may include local degradation (breakdown of tendinous tissues) as well as increased risk of tendon tearing and shoulder arthritis. Therefore, corticosteroid use should be restricted to selected cases.
Currently, intra-articular Hyaluronic Acid (HA) is a well accepted, conservative treatment in patients with knee osteoarthritis. HA is found in healthy tendon sheaths and seems to help lubricate the tendon tissue during movement. Recently, HA has been proposed for the treatment of tendinopathy due to its viscoelastic properties on connective tissue.
Several recent studies have shown evidence that HA injections are a valuable alternative to other conservative treatment methods for chronic shoulder pain. Although we need more studies, the trend is clear. Corticosteroids should be avoided based on their negative side effects and increased risk of further tendon tearing. HA can be used as a safe alternative that appears to promote improved tendon gliding and improved connective tissue organization.
One study looked at intra-articular HA injections to shoulders with Rotator Cuff Tendinopathy (RCT) and impingement. They found significant improvement in function and pain control lasting 6 months in many patients. Conversely, the steroid group had only short lived improvement up to 6 weeks.
Another study looked at HA injections vs. Platelet Rich Plasma (PRP) for RCT tendinopathy. Patients were divided into three groups including HA alone, PRP alone and a group of combined HA + PRP. The PRP group showed superior results to HA at 12 months in both function and pain. The HA + PRP group showed superior results to PRP alone. More importantly with MRI imaging, the HA + PRP group showed enhanced tendon healing when compared to the healing seen in the PRP group alone.
Conclusion: Based on multiple studies, we can now state that PRP plus the addition of HA for treatment of partial rotator cuff tear has the highest regeneration results. HA is clearly superior to corticosteroid injections with regard to safety, long term pain relief and decreased risk of worsening tendon disease in tendinopathy and shoulder impingement,
Here at PICSM, we are committed to attending national and international conferences on regenerative medicine. We are the only clinic in Montana that understands the importance of adding HA for regenerative procedures to the shoulder.