• Posted October 12, 2023

Treatment for Common Rotator Cuff Ailment May Be Useless

Treating shoulder pain with steroid shots or removal of cartilage buildup yields the same result as no treatment at all, a Norwegian research team reports.

They said their findings call into question treatment guidelines for calcific tendinopathy, a painful condition in the shoulder's rotator cuff tendons.

Researchers said the common invasive procedure, known as ultrasound-guided lavage, appears to be useless.

"The study findings should lead to a critical reconsideration of treatment guidelines for this condition, specifically for the use of ultrasound-guided lavage and cortisone injections," said lead researcher Dr. Stefan Moosmayer, a consultant orthopedic surgeon at Martina Hansens Hospital in Gjettum, Norway.

Calcific tendinopathy is a common shoulder condition marked by calcium buildup. But the study, published Oct. 11 in the journal BMJ, calls into question whether calcium buildup is the true cause of the joint pain.

"We over-focus on the calcification itself," Moosmayer said. "There may be other mechanisms which we have not fully understood."

Calcification has long been assumed to be the source of the pain, and treatments aim to remove it. A widely used method is ultrasound-guided lavage, in which saline is injected into the calcium deposits to help dissolve them.

"Benefits from ultrasound-guided lavage or from a steroid injection, however, are no better than from placebo treatment," Moosmayer said.

For the study, 218 patients suffering from shoulder pain were randomly assigned to lavage plus steroid injection; phony lavage plus steroid injection; and phony lavage alone.

After treatment, patients did a home exercise program. After four months, no significant difference in pain and function was found among the three groups -- even in patients whose calcium had disappeared, the researchers found.

Patients given a steroid shot did say they had better pain relief than other participants at two and six weeks after treatment, the study noted. By four months, however, the improvements were no different from the placebo treatment.

"This study does call into question the use of lavage and I think more globally, it calls into question the use of steroids," said Dr. Etan Sugarman, a sports medicine surgeon at Northwell Health in New York City, who reviewed the findings. "Steroid injection is used routinely and repetitively, and I think that that needs to be questioned here."

Conservative treatment can do a lot of good, he said.

"Over time, the likelihood is that they are going to get better, even if they don't do any invasive intervention, but that takes time and that takes patience, and that takes reassurance on the provider's part and a real relationship with the patient," Sugarman said.

Moosmayer said that most patients' shoulder pain will eventually go away by itself.

"Patients should take their time," he said. "It's a good thing to treat them noninvasively for a long time, because it appears a great number will do very well."

A U.S. doctor who cowrote an editorial published with the study said too many lavage procedures are done for shoulder pain. But how many are done in the United States each year isn't known.

"Ultrasound-guided lavage procedure for rotator cuff calcific tendinopathy is currently overused, follow-up X-rays to see if the calcium is gone are likely not needed, and more studies are needed looking at if the procedure is more effective if done earlier on when symptoms start," said Dr. David Robinson, a sports medicine physiatrist at Mass General Brigham and Spaulding Rehabilitation Hospital in Boston.

"If you've had pain from calcific tendinopathy for years, then an ultrasound-guided lavage procedure isn't likely to provide much additional help, but symptoms will still likely improve with time alone and a home exercise program," Robinson added.

More information

The Cleveland Clinic has more about calcific tendinopathy.

SOURCES: Stefan Moosmayer, MD, PhD, consultant orthopedic surgeon, Martina Hansens Hospital, Gjettum, Norway; David Robinson, MD, sports medicine physiatrist, Mass General Brigham and Spaulding Rehabilitation Hospital, Boston; Etan Sugarman, MD, sports medicine surgeon, Northwell Health, New York City; BMJ, Oct. 11, 2023