What is the treatment for a subchondral cyst at the greater tuberosity of the shoulder glenohumeral joint using corticosteroid (CS) injection?

Corticosteroid Injection for Subchondral Cyst in the Greater Tuberosity of the Shoulder Glenohumeral Joint

The efficacy of corticosteroid injections for subchondral cysts in the greater tuberosity of the shoulder glenohumeral joint is not well established, with insufficient evidence to either support or refute this treatment approach.

Evidence on Corticosteroid Injections for Glenohumeral Joint Conditions

• Current guidelines from the American Academy of Orthopaedic Surgeons (AAOS) are unable to recommend for or against the use of injectable corticosteroids in the treatment of glenohumeral osteoarthritis (Grade I recommendation, Level V evidence) 1

• Corticosteroid injections are widely used in clinical practice for patients with shoulder pain of various etiologies, often in conjunction with physical therapy as an initial treatment 1

• For glenohumeral joint conditions, corticosteroid injections may be administered into the glenohumeral joint or subacromial space 1

• Observational studies have shown significant short-term pain reduction after either glenohumeral or subacromial injection, but long-term pain reduction has not been verified 1

Considerations for Subchondral Cysts Specifically

• No specific high-quality studies address corticosteroid injections directly into subchondral cysts of the greater tuberosity in humans 1

• When administering intra-articular injections, the FDA recommends:

  • For larger joints (like the shoulder): 5-15 mg of triamcinolone acetonide 2
  • Doses up to 40 mg for larger areas may be used in adults 2

• Ultrasound guidance may improve accuracy and outcomes of glenohumeral injections:

  • One study of ultrasound-guided glenohumeral corticosteroid injections for adhesive capsulitis showed 55.9% of patients reported >75% pain relief within three months 3
  • Ultrasound guidance helps ensure proper needle placement 1, 3

Treatment Algorithm for Subchondral Cyst in the Greater Tuberosity

1. Confirm diagnosis with appropriate imaging:

   • MRI is preferred to visualize the subchondral cyst and rule out other pathologies 1
   • Ultrasound may be used as a diagnostic tool for shoulder soft tissue injury 1

2. Consider corticosteroid injection if:

   • Patient has pain associated with the subchondral cyst 1
   • Conservative measures (physical therapy, NSAIDs) have failed 1

3. Injection technique:

   • Use ultrasound guidance to ensure accurate placement 3
   • For glenohumeral joint: 5-15 mg triamcinolone acetonide with local anesthetic 2
   • Strict aseptic technique is mandatory 2

4. Post-injection management:

   • Monitor for short-term pain relief 1
   • Continue appropriate physical therapy and rehabilitation 1
   • If inadequate response, consider alternative treatments 1

Alternative Treatment Options

• Injectable viscosupplementation may be considered as an option for glenohumeral osteoarthritis (Grade C recommendation, Level IV evidence) 1

• For persistent pain, surgical options may be considered depending on the extent of pathology and patient factors 1

Important Caveats and Limitations

• The evidence specifically for subchondral cysts in the greater tuberosity is extremely limited 1

• Veterinary studies on subchondral cysts in horses have shown some success with intralesional corticosteroid injections, but these cannot be directly extrapolated to humans 4, 5, 6

• Potential complications of corticosteroid injections include:

  • Post-injection pain flare
  • Infection
  • Tissue atrophy if injected into surrounding tissues rather than the joint 2
  • Tendon weakening with repeated injections 2

• Ensure the injection is made into the joint space rather than the tendon substance to avoid tissue atrophy 2