Background: Statins are essential for managing cholesterol levels but can induce musculoskeletal side effects, including tendinopathy of the shoulder. Rotator Cuff Disease (RCD) is one of the most common shoulder tendinopathy. The aim of the present study is to report a clinical case of statin-induce RCD after performing a systematic review on the subject. Materials and Methods: We performed a systematic review of the literature and report the case of a 49-year-old man with statin-induced RCD treated with a personalized individual rehabilitation project (IRP) (steroid and HA injections, mesotherapy, and therapeutic exercise) to investigate the relationship between statins and shoulder tendinopathy. The review followed PRISMA guidelines (2020 version), searching PubMed, Web of Science, and SCOPUS. Results: Out of a total of 217 articles, three cohort studies were suitable for our review. Conflicting evidence emerged regarding the association between statins and shoulder tendinopathy from the included papers. The case report describes a patient who experienced RCD after increasing atorvastatin dosage, with symptoms improving after dose reduction and a multimodal personalized IRP. Conclusions: Statins may contribute to tendon injury by altering the extracellular matrix and cell membrane integrity. While tendinopathy and statin relation is still under discussion, clinicians should monitor patients for tendinopathy and consider switching to alternative treatments in case symptoms arise. The case report demonstrated the successful management of statin-induced RCD with a multimodal personalized IRP. Further research is needed to clarify the relationship between statins and shoulder tendinopathy. Early diagnosis and appropriate personalized management are crucial for optimizing patient outcomes.

This evidence-based clinical practice guideline (CPG) aims to guide clinicians with recommendations covering the assessment, treatment, and prognosis of adults with shoulder pain with suspected rotator cuff (RC) tendinopathy, the nonsurgical medical care and rehabilitation of adults with RC tendinopathy, as well as the return to function and sport for elite and recreational athletes. This CPG includes recommendations for managing RC tendinopathy with or without calcifications and partial-thickness RC tears. J Orthop Sports Phys Ther 2025;55(4):235-274. Epub 30 January 2025. doi:10.2519/jospt.2025.13182.

There is growing evidence that hyaluronic acid (HA) injections can significantly improve pain and function in rotator cuff tendinopathy. However, there is no consensus regarding the optimal parameters for HA injections. This narrative review explores the procedural considerations for HA injections in rotator cuff tendinopathy.

A literature search using Pubmed and Cochrane was conducted to assess procedural considerations for HA injections in rotator cuff tendinopathy including the type of HA (linear vs. cross-linked), the molecular weight (low, moderate, and high), the combination of HA with other products, the number and frequency of injections, the injection guidance, and the adverse effects.

Nine randomized-controlled trials and two prospective non-randomized studies assessed the efficacy of HA injections for rotator cuff tendinopathy, and their characteristics were thoroughly analyzed. Two studies compared the efficacy of different molecular weight HA. One study assessed the efficacy of HA combined with extracorporeal shockwave therapy.

Highlights of the findings include the clinical benefits of HA injections for rotator cuff tendinopathy, the better tolerability of low molecular weight HA compared to high molecular weight, the safer adverse effect profile of HA compared to glucocorticoid injections, and the synergistic effect of HA and extracorporeal shockwave therapy.

Sub-acromial injections are a therapeutic option for rotator cuff injuries; however, evidence regarding the most effective drug in this context is unclear, which needs to be investigated.

To evaluate the effectiveness of various sub-acromial injections for rotator cuff injuries.

We conducted a systematic review and pair-wise and network meta-analyses of randomized clinical trials (RCTs) comparing sub-acromial injections for rotator cuff injuries. The interventions evaluated were hyaluronic acid (HA), platelet-rich plasma (PRP), prolotherapy, and corticosteroids. The outcomes of interest were pain and functional improvement, which were evaluated with standardized scores. The Risk of Bias 2 tool and the Grading of Recommendations, Assessment, Development and Evaluation methodology were used to assess data quality.

Twenty RCTs, comprising 1479 participants, were included. In the short term, HA achieved the best outcomes [pain mean difference (MD) = -1.48, 95% confidence interval (CI) -2.37 to -0.59; function MD = 10.18, 95%CI: 4.96-15.41]. In the medium term, HA, PRP, HA + PRP, and corticosteroids were not superior to placebo in improving pain. Based on function, HA + PRP was superior to placebo, corticosteroids, and PRP (MD = 26.72; 95%CI: 8.02-45.41). In the long term, HA, PRP, and corticosteroids were not superior to placebo in reducing pain. However, based on function, HA + PRP, PRP, and HA were superior to placebo, and HA + PRP had the best result (MD = 36.64; 95%CI: 31.66-33.62).

HA provides satisfactory short-term results, while HA with PRP demonstrates functional improvement in the medium and long terms. However, no intervention maintained the pain-relief effect on > 3-month follow-up.

Hyaluronic acid (HA) has been largely used in clinical practice for rheumatic diseases. However, the effects of oral HA on these diseases are poorly understood.

To review articles evaluating oral HA's effects on rheumatic patients.

PubMed was searched for articles on oral HA and rheumatic diseases between 1966 and May 2024.

Eleven articles were found with 597 patients. The diseases investigated were OA (n=10) and low back pain (n=1). Age varied from 40 to 70 years old, and female gender ranged from 43% to 75%. Follow-up ranged from 4 weeks to 12 months. The oral HA dosage varied from 30 mg to 300 mg/day. Concerning outcome, 9/11 articles observed improvement in rheumatic diseases in the following parameters: VAS pain, WOMAC, joint function, SF-36, Lequesne index, and stiffness. Two studies evaluated cytokines and observed a reduction of them after oral HA therapy. Adverse effects were rare and mild.

Oral HA seems to be a safe and effective therapy for OA and low back pain patients, although more studies should be done on the latter condition.

Medial gastrocnemius strain (MGS), is the most common cause of mid-calf pain in athletes due to the stretch of the gastrocnemius muscle when the knee is in extension and the ankle is in dorsiflexion. Chronological age and previous calf injury are the most substantial risk factors for MGS, including high body mass index, previous lower limb injuries, L5 radiculopathy, and inadequate warm-up. The dominant presentation of MGS is a pain that can be diverse from acute to latent, which is felt in the posteromedial aspect of the calf and is often preceded by a feeling of a pop. The signs of MGS include antalgic gait, ecchymosis, swelling, local tenderness, and sometimes a palpable gap felt along the muscle. Passive dorsiflexion of the ankle or resistive ankle plantarflexion with knee extension can indicate a more severe injury, while functional tests can illicit milder injuries of calf muscles-including gastrocnemius. The diagnosis of MGS is usually made by clinical evaluation. However, imaging modalities-including magnetic resonance imaging and ultrasound-can be helpful in case of suspicion. In most cases of MGS, the cornerstone of treatment is nonoperative rehabilitation, which can be performed as a 4-phase program and should be tailored individually. Some instances of MGS are referred for early or later surgical treatment if indicated. In this article, we review the literature about various aspects of MGS, from diagnosis to treatment and rehabilitation, and propose a structured approach to this injury.

Patellar tendinopathy is a frequent overuse injury in sports that can cause significant pain and disability. It requires evidence-based guidelines on effective prevention and management. However, optimal treatments remain uncertain. We aimed to analyze available meta-analyses to summarize treatment recommendations, compare therapeutic modalities, examine included trials, and offer methodological suggestions to improve future systematic reviews. Meta-analyses were systematically searched for in PubMed (PROSPERO: CRD42023457963). A total of 21 meta-analyses were included. The AMSTAR-2 scale assessed study quality, which was low, with only 23.8% of the meta-analyses being of moderate quality, and none were considered to be of high quality. Heterogeneous outcomes are reported. Multiple platelet-rich plasma (PRP) injections appear superior to eccentric exercises and provide lasting improvements compared to eccentric exercises when conservative treatments fail. Extracorporeal shockwave therapy (ESWT) also seems superior to non-operative options and similar to surgery for patellar tendinopathy in the long term. However, evidence for eccentric exercise efficacy remains unclear due to inconclusive findings. Preliminary findings also emerged for genetic risk factors and diagnostic methods but require further confirmation. This review reveals a lack of high-quality evidence on optimal patellar tendinopathy treatments. While PRP and ESWT show promise, limitations persist. Further rigorous meta-analyses and trials are needed to strengthen the evidence base and guide clinical practice. Methodological enhancements are proposed to improve future meta-analyses.

This review article discusses the anatomy and histopathology of the patellar tendon, as well as the risk factors and common interventions for patellar tendinopathy (PT) with a view to guide clinicians in treating athletes with patellar tendon pain. PT, or jumper's knee, refers to a chronic injury to the patellar tendon that affects athletes who engage in jumping and explosive movements. The condition is characterized by degeneration and disorganization of the collagen fibers in the tendon, an increase in mucoid ground substance, and fibroblast proliferation. Risk factors for patellar tendinopathy include participation in jumping sports, a greater counter-movement jump height, and training on hard surfaces. Nonoperative treatments for patellar tendinopathy include relative rest, stretching and strengthening exercises, and correction of biomechanical abnormalities. Surgery and other procedures, such as extracorporeal shockwave therapy (ESWT) and injection therapies, may be considered for patients who do not respond to conservative measures.

The Achilles tendon is the thickest and strongest tendon of the human body, and it is frequently injured during sports activity. The incidence of Achilles tendon pathologies has increased over recent decades, especially in the last few years, because of increased sports participation among the general population and due to the diffusion of competitive sports at a high level. Tendinopathies are common in athletes and in middle-aged overweight patients. The term "tendinopathy" refers to a condition characterised clinically by pain and swelling, with functional limitations of tendon and nearby structures, and consequently to chronic failure of healing response process. Tendinopathies can produce marked morbidity, and at present, scientifically validated management modalities are limited. Despite the constantly increasing interest and number of studies about Achilles tendinopathy (AT), there is still not a consensual point of view on which is the best treatment, and its management is still controversial. AT can be treated conservatively primarily, with acceptable results and clinical outcomes. When this approach fails, surgery should be considered. Several surgical procedures have been described for both conditions with a relatively high rate of success with few complications and the decision for treatment in patients with AT should be tailored on patient's needs and level of activity. The aim of this article is to give insights about the pathogenesis and most used and recent treatment options for AT.

Imaging-guided tendon procedures aim to reduce pain and increase function by controlling inflammation and stimulating healing. Ultrasound is the preferable guiding modality due to its high resolution and real-time demonstration of the tendinous anatomy and needle positioning. The technique includes appropriate patient positioning, which varies depending on the targeted tendon, as well as sterile and proper draping. For most procedures, we prefer the "in-plane" approach, which demonstrates the entire needle as it advances through different tissue layers. Upper limb injections commonly use corticosteroids and anesthetics with different reported short- and long-term results depending on the tendon treated; better results are obtained in the treatment of tenosynovitis (sliding tendons such as trigger finger and De Quervain's tenosynovitis). Shoulder and elbow tendinopathies (anchor tendons) may also benefit from injections containing irritants or healing stimulants such as dextrose (prolotherapy) and platelet-rich plasma or by the stimulation of healing via tendon perforations (fenestration). The hyaluronic acid injection has also been used in the treatment of both tenosynovitis and tendinopathies. For tendons passing through osteofibrous tunnels, an additional release may be performed, and the techniques are discussed in this review. Therefore, this article provides practicing musculoskeletal radiologists and trainees with a comprehensive review of tendon injection musculoskeletal image-guided procedures.

To compare the clinical effectiveness of three common shoulder injections mentioned in the guidelines [corticosteroid, sodium hyaluronate (SH) and platelet-rich plasma (PRP)] on rotator cuff tears.

The PubMed, Embase and Cochrane Library databases were systematically searched up to June 1, 2022, for randomized controlled trials (RCTs) and prospective studies on the three injection therapies for rotator cuff tears. The main results were pain relief and functional improvement at 1-5 months and over 6 months, pooled using a network meta-analysis and ranked by SUCRA score. The risk of bias of the included studies was assessed using the Cochrane Collaboration tool.

Twelve RCTs and 4 prospective studies comprising a total of 1115 patients were included in the review. Three prospective studies were judged to be at high risk of selection bias and performance bias, and one was considered as having a high risk of detection bias. SH injection ranked first in the short term in pain relief (MD: - 2.80; 95%CI - 3.91, - 1.68) and functional improvement (MD:19.17; 95%CI 12.29, 26.05), while PRP injection obtained better results in the long term in both pain relief (MD: - 4.50; 95%CI - 4.97, - 4.03) and functional improvement (MD:11.11; 95%CI 0.53,21.68).

PRP injection has the potential to successfully treat rotator cuff tears as an alternative to corticosteroids in the long term, in terms of either therapeutic efficiency or adverse effects, followed by SH injection. More research is needed to make high-quality recommendations on treatment options for injection treatments of rotator cuff tears.