Ultrasound guided injections for shoulder bursitis in Wandsworth
Shoulder complaints are the third most common reason for musculoskeletal GP appointments in the UK. Anywhere from 1.5% to 3% of adults present to their GP with shoulder pain at some point in their life. Women tend to report shoulder pain more than men with the peak age ranging from 45-64. Shoulder pain is an intransigent problem with almost half of all patients visiting their GP more than once (Artus et al 2017, van der Windt et al 1995, Linsell et al 2005, Friedman et al 2017). One of the most common shoulder problems comes from the rotator cuff tendons that sit in the subacromial space along with the subacromial bursa. This may be termed shoulder or subacromial impingement syndrome, subacromial bursitis or rotator cuff tendinopathy. Physiotherapy and strengthening exercises are usually very helpful in resolving rotator cuff problems, however what happens when you pain doesn’t improve? Ultrasound guided steroid injections for shoulder pain. Book a shoulder pain assessment and treatment session where we can assess, ultrasound scan and diagnose your shoulder pain.
Do subacromial steroid injections help?
Ultrasound guided injections into the subacromial bursa are usually performed with corticosteroid and local anaesthetic to reduce local pain and inflammation. However, it remains inconclusive as to whether corticosteroid injections are effective for the long-term resolution of subacromial impingement syndrome. It has been reported that subacromial steroid injections are affective for up to 9 months and superior to oral non-steroidal anti-inflammatory drugs (Messina at al 2015). A meta-analysis by Arroll and Goodyear-Smith (2005) was the first to show a significant benefit for subacromial corticosteroid injection versus placebo for a painful shoulder. The numbers needed to treat range between 1.4 and 2.2 patients and were clinically significant. More recently and contrary to Arroll and Goodyear-Smith’s findings a meta-analysis by Mohamadi et al (2017) found that corticosteroid injections provide minimal transient pain relief in a small number of patients with rotator cuff tendinitis at 4-8 weeks post injection. They found no differences three months after injection between steroid injection and placebo and for every five patients treated with a corticosteroid injection one would experience a slight, transient reduction of symptoms to mild pain. Mohamadi et al (2017) concluded SA/SD corticosteroid injections have limited appeal.
Are there other effective subacromial injections?
Ultrasound guided platelet-rich plasma (PRP) injections are now being used as an alternative to steroid injections as PRP contains more than 30 bioactive proteins such as growth factors within the platelets (Say et al 2016). Rotator cuff pathology (tendinopathy / tears) show reduced stem cell numbers, disorganised matrix and hypoperfusion (Phadke et al 2019). It is hypothesised that PRP injections improve these deficiencies. The evidence base for the use of ultrasound-guided PRP injection for rotator cuff tendinopathy and tears is still emerging, and due to heterogenicity of methodology it is still unclear as to its effectiveness. However, using PRP injections avoids the unwanted side effects of steroid injections such as steroid flare, fat atrophy or skin depigmentation.
There is a large body of research investigating the use of PRP in rotator cuff tendinopathy (Lin et al 2020). Say at et (2016) conducted a study on 60 subjects who were offered either a single dose injection of PRP or steroid for subacromial impingement. Both groups were also instructed to perform standard rotator cuff exercises for 6 weeks. Patients were evaluated before, and 6 weeks and 6 months after the injection. Patients that had the steroid injection fared better regarding self-reported pain at 6 weeks and 6 months compare to those who had the PRP injection. However, the study was not randomised, placebo controlled, and had a small cohort. Ibrahim at et (2019) also conducted a study to compare the efficacy of ultrasound guided PRP versus corticosteroid injection in the treatment of rotator cuff tendinopathy. 30 patients with RCT were randomly divided into two groups of 15 and received either ultrasound guided subacromial injection of 2ml of PRP or with a combination of 1ml methylprednisolone and 1 ml of lidocaine. Patients also did an exercise program for 7 weeks including rotator cuff strengthening exercises. Two months post injection there was a significant improvement in pain and range of movement in each group with no significant difference between the groups. Ibrahim at et (2019) concluded that steroid injections may provide symptomatic relief but do not promote healing which makes PRP injection a good alternative for RCT. Niazi et al (2020) assessed the effect of ultrasound guided PRP on patient symptoms and supraspinatus tendon thickness in cases of rotator cuff tendinopathy. Thirty subjects received a single injection of 5-7ml PRP into the subacromial bursa. This study showed a decrease in pain and an increase in function at four, eight, 12- and 24-weeks post injection, however there was no difference in tendon thickness until 24 weeks where tendon thickness reduced.
To date, studies demonstrate emerging evidence for the effectiveness of PRP for rotator cuff pathology, however, due to the heterogeneity in the study design (studies comparing PRP to placebo, steroid, physical therapy or dry needling) there is no consensus in the literature as to the number of injections, the site of injection (bursa or tendon), PRP preparation or the number of injections required.
Which injection should you have?
This is a discussion to be had with your treating therapist. It is still most common to start with an ultrasound guided steroid injection into the shoulder bursa to help settle pain and inflammation. If this hasn’t helped it is acceptable to move on to PRP or even a hyaluronic acid injection.
Ultrasound guided injections for shoulder pain
If you’re struggling with shoulder pain or think you have shoulder bursitis and want an ultrasound scan and discuss the option of an injection for pain relief call 0203 322 9455.
References
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