Will an ultrasound (USS)-guided corticosteroid injection be effective for a 68-year-old female with a full-thickness tear of the anterior aspect of the supraspinatus tendon and subacromial bursitis, who has not improved with physiotherapy?

From the Guidelines

An ultrasound-guided cortisone injection may provide temporary relief for this 68-year-old female with a supraspinatus full thickness tear and subacromial bursitis, but it is unlikely to be a definitive solution. The injection would target the inflamed subacromial bursa, potentially reducing pain and improving function for several weeks to months by decreasing inflammation. However, given the significant full thickness tear (11 x 14mm) that has not responded to physiotherapy, the injection should be considered a temporary measure rather than a curative treatment. The cortisone would help with the bursitis and impingement symptoms but cannot repair the torn tendon.

Key Considerations

• The evidence for the use of subacromial injections in patients with rotator cuff tears is inconclusive, as noted in a study published in The Journal of the American Academy of Orthopaedic Surgeons 1.
• The study found that while some patients may experience short-term improvement with corticosteroid injections, there is no statistically significant difference in pain or tenderness up to 6 weeks after injection compared to lidocaine injection alone 1.
• Another study also reported conflicting results for the effect of subacromial corticosteroid injections, with varying outcomes for pain and function 1.

Recommendations

• After the injection, the patient should continue modified physical therapy to maintain shoulder function.
• Given her age and the size of the tear, surgical options such as arthroscopic repair might need to be considered if conservative measures fail.
• The decision should balance the potential short-term benefits of pain relief against the limited long-term efficacy for addressing the underlying structural problem.

Important Points to Consider

• The patient's lack of response to physiotherapy and the significant size of the tear (11 x 14mm) suggest that a more definitive treatment may be necessary.
• The potential risks and benefits of corticosteroid injections, including the potential adverse effects on rotator cuff tendon biology and healing capacity, should be carefully considered 1.

From the Research

Efficacy of USS Guided Cortisone Injection

• The patient has a full thickness tear of the supraspinatus tendon, subacromial bursitis, and impingement, with no improvement after physiotherapy 2, 3, 4, 5, 6.
• Studies have shown that USS guided corticosteroid injection can be effective in treating subacromial bursitis and impingement syndrome 2, 3, 4, 5, 6.
• A study published in 2006 found that subacromial injections of corticosteroids and local anesthesia can substantially reduce pain and increase range of motion of the shoulder in patients with subacromial impingement syndrome 3.
• Another study published in 2021 found that ultrasound-guided corticosteroid injection into the subacromial-subdeltoid bursa was effective and superior to hyaluronic acid and normal saline injection for treating chronic subacromial bursitis 4.
• A 2023 study found that combination of corticosteroid subdeltoid injections and physiotherapy was more effective than either treatment alone in chronic subacromial bursitis, but the recurrence rate was least in the physiotherapy group 5.
• A 2017 study found that patients with ultrasonographic evidence of subacromial bursitis can expect better outcomes with subacromial corticosteroid injection 6.

Considerations for Treatment

• The patient's age (68 years old) and the presence of a full thickness tear of the supraspinatus tendon should be taken into consideration when deciding on treatment 2, 3, 4, 5, 6.
• The patient's lack of improvement with physiotherapy suggests that USS guided corticosteroid injection may be a viable treatment option 2, 3, 4, 5, 6.
• The presence of subacromial bursitis and impingement syndrome, as well as the patient's symptoms, should be carefully evaluated before proceeding with treatment 2, 3, 4, 5, 6.