Do subacromial steroid injections help a patient with a torn supraspinatus tendon?

Subacromial Steroid Injections for Torn Supraspinatus: Evidence-Based Recommendation

For patients with a confirmed full-thickness supraspinatus tear who have failed conservative management including prior steroid injections, surgical rotator cuff repair is the definitive treatment, as 81% of surgical patients achieve excellent results versus only 37% with continued non-surgical management. 1

Clinical Context: Full-Thickness vs Partial-Thickness Tears

The evidence diverges significantly based on tear severity:

Full-Thickness Tears

• Steroid injections have inconclusive evidence for full-thickness rotator cuff tears, with five level II studies showing conflicting results for pain and function outcomes at 2-6 weeks 2
• The American Academy of Orthopaedic Surgeons cannot recommend for or against subacromial corticosteroid injections specifically for full-thickness tears due to inconsistent study results 2
• Surgical repair becomes the primary recommendation when chronic symptomatic full-thickness tears persist despite prior steroid injections, with surgical patients experiencing significantly less pain with shoulder range of motion and at night 1

Partial-Thickness Tears

• Steroid injections provide short-term benefit (1 month) for partial supraspinatus tears, with significant pain reduction and functional improvement 3
• However, benefits do not persist beyond 6 months, with corticosteroid groups showing no significant improvement in pain or function scores between 1-month and 6-month follow-up 3
• One high-quality 1996 study demonstrated that subacromial corticosteroid injection effectively decreased pain and increased shoulder range of motion (24° improvement in forward elevation) for subacromial impingement syndrome at mean 33-week follow-up 4
• Platelet-rich plasma (PRP) shows superior long-term outcomes compared to corticosteroids for partial tears, with continued improvement at 6 months and actual reduction in tear size (3.39 mm in coronal plane, p=0.003) 3, 5

Algorithm for Clinical Decision-Making

Step 1: Confirm tear type and severity with MRI or ultrasound 1

Step 2: For full-thickness tears:

• If patient has failed prior steroid injections → refer to orthopedic surgery for repair evaluation 1
• If surgery declined/contraindicated → consider structured physical therapy (though evidence is weak), avoid repeated steroid injections 1
• Do not perform multiple repeated corticosteroid injections as this may compromise future surgical outcomes and tendon biology 1

Step 3: For partial-thickness tears:

• First-line: Single subacromial corticosteroid injection can provide 1-month pain relief and functional improvement 3, 4
• Consider PRP injection instead if available, as it provides superior 6-month outcomes and may reduce tear size 3, 5
• If symptoms return after initial steroid benefit (typically 3-6 weeks), do not repeat steroid injections—consider PRP or surgical evaluation 3

Step 4: For impingement syndrome without confirmed tear:

• Subacromial corticosteroid injection is effective for short-term therapy, substantially decreasing pain and increasing range of motion 4
• Combine with exercise therapy and NSAIDs as initial treatment 2

Critical Pitfalls to Avoid

• Avoid interpreting MRI within 7 weeks of steroid injection, as corticosteroids can penetrate the supraspinatus tendon and create transient signal changes that mimic full-thickness tears on imaging 6
• Never assume asymptomatic tears require surgery—only symptomatic tears with failed conservative management warrant surgical referral 1
• Do not use opioids as first-line treatment—reserve strictly for rescue analgesia 1
• Avoid repeated steroid injections without clear sustained benefit, as evidence shows no long-term efficacy beyond 6 weeks and potential adverse effects on tendon healing 2, 3

Special Considerations

• Age affects surgical outcomes: Postoperative healing rates are inconsistent in elderly patients, which should factor into surgical decision-making 1
• Workers' compensation status correlates with less favorable outcomes after rotator cuff repair 2
• Muscle quality matters: Preoperative infraspinatus fatty degeneration and muscle atrophy correlate with worse surgical outcomes and healing 2

When Conservative Management Continues

If surgery is declined or contraindicated for full-thickness tears, the evidence cannot definitively support specific interventions 2:

• Exercise programs (supervised or unsupervised) show some improvement in two level IV studies but lack strong evidence 2, 1
• NSAIDs, activity modification, ice, heat, iontophoresis, massage, TENS, and PEMF lack sufficient evidence for recommendation 2
• Additional subacromial injections are not recommended given potential adverse effects on tendon biology 1