Can Synvisc (hylan G-F 20) injections be administered in the shoulder to treat osteoarthritis?

Can Synvisc Be Given in the Shoulder?

Yes, Synvisc (hylan G-F 20) injections can be administered in the shoulder for glenohumeral osteoarthritis, as the American Academy of Orthopaedic Surgeons recognizes injectable viscosupplementation as a treatment option for this condition. 1

Guideline-Based Recommendation

The AAOS clinical practice guideline on glenohumeral osteoarthritis provides a Grade C recommendation (weak evidence, Level IV) supporting the use of injectable viscosupplementation, including Synvisc, for treating shoulder OA. 1

• The guideline specifically references a study by Silverstein et al. that assessed patients with glenohumeral OA treated with three weekly Hylan G-F 20 (Synvisc) injections. 1
• Patients received 2 mL injections once weekly for 3 weeks, following the same protocol used for knee injections. 1
• Improvements were documented in Visual Analogue Scale (VAS) pain scores, Simple Shoulder Test (SST), and UCLA scores at 1,3, and 6 months after the final injection. 1, 2

Clinical Context and Evidence Quality

While viscosupplementation is an option for shoulder OA, the evidence supporting its use is notably weaker than for other joints:

• Only one industry-supported Level IV study met the AAOS inclusion criteria for shoulder viscosupplementation, compared to more robust evidence for knee OA. 1
• The AAOS guideline emphasizes that management of glenohumeral OA remains controversial and that scientific evidence can be significantly improved. 1
• Despite limited evidence, viscosupplementation is recommended as an option after failed steroid injections and before considering surgical intervention. 2, 3

Treatment Algorithm Position

Synvisc injections fit into the shoulder OA treatment algorithm as follows:

• First-line: Exercise-based physical therapy and rotator cuff strengthening remain the foundation of treatment. 3
• Second-line: Injectable viscosupplementation (including Synvisc) is an option when conservative measures provide insufficient relief. 2, 3
• Consider after: Failed corticosteroid injections (though evidence for corticosteroids is also inconclusive with Grade I recommendation). 1, 3
• Before: Arthroscopic treatments (insufficient evidence) or arthroplasty procedures. 2, 3

Administration Protocol

Based on the evidence reviewed by AAOS:

• Administer three intra-articular injections of Hylan G-F 20 at weekly intervals (1-week apart). 1, 2
• Each injection consists of 2 mL of Synvisc. 1
• Monitor for improvements in pain and function at 1,3, and 6 months post-treatment. 1, 2

Important Caveats and Safety Considerations

Risk of acute local reactions: While Synvisc is generally safe, be aware that patients receiving multiple courses of hylan G-F 20 treatment have a significantly increased risk of painful acute local reactions (21% vs. 2% in single-course patients). 4

• These reactions can be severe enough to require unscheduled care but typically resolve with corticosteroid injection without sequelae. 4
• Counsel patients seeking repeat courses about this increased risk. 4

Limited shoulder-specific data: The recommendation for shoulder use is extrapolated primarily from knee OA literature and one shoulder-specific study, so outcomes may vary. 1, 3

Patient selection: Viscosupplementation may be most appropriate for patients with early-to-moderate OA who have failed conservative management but are not yet candidates for surgical intervention, particularly younger patients (under 50 years) where arthroplasty carries concerns about prosthetic loosening and decreased survivorship. 2, 3