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.

Shoulder pain is the third leading cause of musculoskeletal complaints in primary care clinics. Its prevalence varies from 14% to 34%. Among all the structures that can cause shoulder pain, the most vulnerable to injury is the tendon of the supraspinatus muscle. The ideal management protocol is still unknown. To date, little is known in the literature about the use of ultrasound-guided suprascapular nerve block as a treatment for supraspinatus muscle tendinitis. Our objective was to assess the effects of the association of a single ultrasound-guided suprascapular nerve block combined with home-based rotator cuff exercises to reduce pain and improve shoulder functioning in patients with supraspinatus tendinitis.

We evaluated the effect of a single ultrasound-guided suprascapular nerve block on pain and functioning of people with supraspinatus tendinitis. Diagnosis was performed using the positive Jobe test. Due to large disparity between clinical and radiological findings, only clinical diagnostic criteria were used to select patients. This was a double-blind, randomized, controlled, clinical study in which patients in the intervention group (n = 42) received a single injection of 5 ml of 2% lidocaine, while in the control group (n = 41) patients underwent the same procedure receiving saline solution 0.9%. All patients received face to face instructions by an experienced physiotherapist and a leaflet explaining home-based exercises. Pain and functioning were assessed using the Shoulder Pain and Disability Index (SPADI) questionnaire before the procedure, one week and 12 weeks after the procedure.

Patients in both groups improved significantly since the initial evaluation until the 12th week. Intervention group SPADI (pre, 1 week, 12 weeks): 75.80 ± 18.96, 56.25 ± 31.37, 46.31 ± 31.41 (p < 0.001); Control group SPADI: 75.49 ± 16.67, 50.51 ± 27.58, 49.37 ± 30.90 (p < 0.001). However, there were no significant differences between groups (p = 0.291).

We concluded that both lidocaine and saline ultrasound-guided suprascapular nerve blocks reduce pain and improve shoulder functioning in patients with supraspinatus tendinitis. Unexpectedly, the same block performed with saline showed similar results and effects.

ClinicalTrials.gov, identifier [NCT02495818].

As sports have increased in popularity, the incidence of tendinopathy has also grown dramatically. Nonoperative techniques and treatments used to address these pathologies continue to evolve and improve. One such treatment, prolotherapy (PrT), has become increasingly popular and may provide patients with an alternative nonoperative treatment option.

To review high-quality randomized controlled trials (RCTs) that analyzed PrT treatments for the most common tendinopathies. Specifically, this review aims to provide meaningful data regarding methods and outcomes for each condition treated and guide professionals who are considering PrT as a treatment option.

Systematic review; Level of evidence, 2.

All RCTs published in English between January 1, 1980, and July 30, 2021, and reported in Embase, Medline, and Web of Science databases were reviewed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. After the initial search, a total of 3264 articles were identified. Studies analyzing sports medicine injuries and musculoskeletal pathologies using an RCT design were included, while case-reports, case-studies, reviews, and observational studies were excluded. Two independent researchers reviewed the search results, and conflicts were resolved by discussion of inclusion and exclusion criteria among all authors. The articles' quality was evaluated using the Cochrane tool for assessing the risk of bias. Statistical analysis and graphical representations were performed using SPSS Version 28.00.

A total of 20 articles, including 1136 patients, met the inclusion criteria and were included in the study. Overall, in 85% of the studies, PrT was found to be effective in the treatment of tendinopathy. Specifically, PrT was superior to or as effective as the control in 83% (10/12) of the studies analyzing lateral epicondylitis (LE) and rotator cuff (RC) tendinopathies and in 88% (7/8) of the studies on plantar fasciitis (PF), Osgood-Schlatter disease (OSD), and Achilles tendinosis (AT). LE, RC, and PF tendinopathies were the most studied conditions (17/20 studies), while AT and OSD were the least studied (3/20 studies). Of the studies, 95% (19/20) used dextrose solutions, with only 1 using solutions of 2.5% phenol, 25% glycerin, and 25% dextrose in sterile water.

Our systematic review suggests that PrT appears to be a promising alternative treatment for common tendinopathies. Most studies used a hypertonic dextrose solution. Even though further, larger randomized controlled trials comparing PrT with other orthobiologics would be beneficial, based on this review, sports medicine physiciansmay safely pursue PrT as an additional component of conservative treatment.

One of the most prevalent illnesses of the shoulder is rotator cuff tendinosis, which is also a major contributor to shoulder discomfort and shoulder joint dysfunction. According to statistics, rotator cuff tendinosis occurs in 0.3-5.5% of cases and affects 0.5-7.4% of people annually. It will be necessary to conduct a meta-analysis to evaluate the efficacy of hypertonic glucose proliferation therapy in the treatment of rotator cuff problems.

The databases Cochrane PubMed, Library, Web of Science and EMbase, are retrieved by the computer. Individuals with rotator cuff lesions in the intervention group were treated with hypertonic dextrose proliferation therapy, whereas individuals in the control condition were treated with a placebo. Outcome markers for rotator cuff lesions patients; Pursuant to studies, the visual analogue scale (VAS) score, the shoulder pain & disability index (SPADI), & other metrics are used to evaluate the effects of hypertonic dextrose proliferation treatment on individuals with rotator cuff diseases. After carefully evaluating the calibre of the literature, data analysis was performed utilising the RevMan 5.3 programme.

Meta-analysis finally contained 6 papers. In six investigations, the test & control group's VAS scores improved, with the test team's score considerably outperforming the control team [standardized mean difference (SMD): 1.10; 95% Cl: 0.37,1.83; P < 0.01], shoulder pain and disability index (SPADI) score (SMD:8.13; 95% Cl: 5.34,10.91; P < 0.01), Flexion (SMD:5.73; 95% Cl: 0.99,10.47; P < 0.05), Abduction (SMD:6.49; 95% Cl: 0.66,12.31; P < 0.05), Internal rotation (SMD:-1.74; 95% Cl: -4.25,0.78; P = 0.176) and External rotation (SMD:2.78; 95% Cl: -0.13,5.69; P = 0.062).

The findings of this study suggest that individuals with rotator cuff injuries may benefit from hypertonic dextrose proliferation treatment based on the visual analogue scale (VAS) score, the Shoulder Pain and Disability Index (SPADI) score, Flexion, & Abduction. These results must, nevertheless, be supported by high-caliber follow-up research.

Rotator cuff disorders include a broad spectrum of pathological conditions including partial-thickness and full-thickness tears. Studies have shown partial-thickness rotator cuff tear (PTRCT) prevalence to be twice that of full-thickness tears. In the working population, PTRCTs are one of the most common causes of shoulder pain and often result in occupational disability due to pain, stiffness, and loss of shoulder function. Treatment of PTRCTs remains controversial. The purpose of this study was to consolidate the existing high-quality evidence on best management approaches in treating PTRCTs using both nonoperative and operative approaches.

A scoping review with best evidence synthesis was performed as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. MEDLINE (OVID), EMBASE (OVID), Cochrane Library (Wiley), SCOPUS, Web of Science Core Collection, CINAHL Plus with Full Text (EBSCOhost), PubMed Central, and Science Direct were searched from 2000 to March 3, 2023. Level 1 studies, and systematic reviews and meta-analyses that included level 1 and 2 studies, were included.

The search yielded 8276 articles. A total of 3930 articles were screened after removing 4346 duplicates. Application of inclusion criteria resulted in 662 articles that were selected for full-text review. Twenty-eight level 1 studies, 1 systematic review, 4 meta-analyses, and 1 network meta-analyses were included in the best evidence synthesis. Nonoperative strategies included injections (ie, platelet-rich plasma, corticosteroid, prolotherapy, sodium hyaluronate, anesthetic, and atelocollagen), exercise therapy, and physical agents. Operative interventions consisted of débridement, shaving of the tendon and footprint, transtendon repair, and traditional suture anchor repair techniques with and without tear completion. Both nonoperative and operative strategies demonstrated effectiveness at managing pain and functional outcome for PTRCTs. The evidence supports the effectiveness of surgical intervention in treating PTRCTs regardless of arthroscopic technique.

The results of this scoping review do not support superiority of operative over nonoperative management and suggest that both strategies can be effective at managing pain and functional outcome for PTRCTs. Surgery, however, is the most invasive and costly approach, with the highest risk of complications such as infection. Other variables such as patient expectation, treating practitioner bias, or preference may change which modalities are offered and in what sequence.

To investigate the effect of hypertonic dextrose injection on pain and disability in patients with chronic supraspinatus tendinosis. The secondary aim was to evaluate its effect on the tendon range of motion (ROM) and morphology.

Randomized double-blind placebo-controlled trial.

Outpatient clinic.

Individuals (N=57) with symptomatic chronic supraspinatus tendinosis.

Participants were randomly administered ultrasound-guided injections of 20% hypertonic dextrose (study group, n=29) or 5% normal saline (control group, n=28).

The primary outcome measure was visual analog scale (VAS) scores for pain and Shoulder Pain and Disability Index (SPADI) scores. Secondary outcomes included the ROM and ultrasound examination findings of the supraspinatus tendon at baseline and at 2, 6, and 12 weeks postintervention.

The study group exhibited significant improvements in the VAS (mean difference [MD], -2.1; 95% confidence interval [CI], -2.7 to -1.4; P<.001) and SPADI (MD, -11.6; 95% CI, -16.5 to -6.7; P<.001) scores compared with baseline scores at week 2. However, the effect was not sustained to week 6. Flexion ROM increased at weeks 2 (MD, 14.1; 95% CI, 5.7-22.5; P<.001) and 6 (MD, 8.9; 95% CI, 2.4-15.4; P=.003) compared with baseline. The thickness of the supraspinatus tendon improved at weeks 6 (MD, .50; 95% CI, .26-.74; P<.001) and 12 (MD, .61; 95% CI, .37-.84; P<.001) compared with baseline. The ratio of histograms also improved at weeks 6 (MD, .19; 95% CI, .06-.32; P=.002) and 12 (MD, .26; 95% CI, .10-.41; P<.001) compared with baseline.

Hypertonic dextrose injection could provide short-term pain and disability relief in patients with chronic supraspinatus tendinosis. Ultrasound imaging at week 6 revealed changed tendon morphology.

Orthoregeneration is defined as a solution for orthopaedic conditions that harnesses the benefits of biology to improve healing, reduce pain, improve function, and optimally, provide an environment for tissue regeneration. Options include drugs, surgical intervention, scaffolds, biologics as a product of cells, and physical and electro-magnetic stimuli. The goal of regenerative medicine is to enhance the healing of tissue after musculoskeletal injuries as both isolated treatment and adjunct to surgical management, using novel therapies to improve recovery and outcomes. Various orthopaedic biologics (orthobiologics) have been investigated for the treatment of pathology involving the shoulder including the rotator cuff tendons, glenohumeral articular cartilage, glenoid labrum, the joint capsule, and bone. Promising and established treatment modalities include hyaluronic acid (HA); platelet-rich plasma (PRP) and platelet rich concentrates (PRC); bone marrow aspirate (BMA) comprising mesenchymal stromal cells (MSCs alternatively termed medicinal signaling cells and frequently, misleadingly labelled "mesenchymal stem cells"); MSC harvested from adipose, umbilical, or placental sources; factors including vascular endothelial growth factors (VEGF), basic fibroblast growth factor (FGF), platelet-derived growth factor (PDGF), transforming growth factor-beta (TGFβ), bone morphogenic protein (BMP), and matrix metalloproteinases (MMPs); prolotherapy; pulsed electromagnetic field therapy; microfracture and other marrow-stimulation techniques; biologic resurfacing using acellular dermal allografts, allograft Achilles tendons, allograft lateral menisci, fascia lata autografts, and porcine xenografts; osteochondral autograft or allograft); and autologous chondrocyte implantation (ACI). Studies involving hyaluronic acid, platelet rich plasma, and medicinal signaling cells of various origin tissues have shown mixed results to-date as isolated treatments and as surgical adjuncts. Despite varied results thus far, there is great potential for improved efficacy with refinement of current techniques and translation of burgeoning preclinical work. LEVEL OF EVIDENCE: Level V, expert opinion.

Shoulder pain is the third most common type of musculoskeletal disorder and rotator cuff (RC) tendinopathy is the most frequent diagnosis. Ultrasound is the most preferable guidance tool for diagnostic and interventional purposes. The aim of this study is to compare the effectiveness of the prolotherapy injection with corticosteroid injection in patients with RC dysfunction.

Thirty to sixty-five-year-old patients with chronic RC disease were divided into two groups. Ultrasound-guided dextrose prolotherapy of supraspinatus tendon was done for one group and ultrasound-guided corticosteroid injection in the subacromial bursa was done for the other groups. Visual analog scale (VAS) and Shoulder Pain and Disability Index (SPADI) were evaluated for both groups at baseline, 3 and 12 weeks after injections.

Thirty-three patients were included in the result. Both the groups showed significant improvement in VAS and SPADI scores in 3 and 12 weeks after injections compared with preinjection times with no difference between two groups neither in 3 weeks nor in 12 weeks after injections.

Both ultrasound-guided dextrose prolotherapy and CS injections are effective in the management of RC-related shoulder pain in both short-term and long-term with neither being superior to the other. Therefore, prolotherapy may be a safe alternative therapy instead of corticosteroid injection due to lack of its side effects.

Prolotherapy or proliferative therapy is a treatment option for damaged connective tissues involving the injection of a solution (proliferant) which theoretically causes an initial cell injury and a subsequent "proliferant" process of wound healing via modulation of the inflammatory process. Nonetheless, the benefits of dextrose prolotherapy have not been adequately evaluated. Therefore, the present study assesses the effectiveness and superiority of prolotherapy separately in treating dense fibrous connective tissue injuries.

PubMed, Scopus, and Embase were searched from the earliest record to February 18, 2019. This study included randomized controlled trials whichBoth analysis at individual studies level and pooled meta-analysis were performed.

Ten trials involving 358 participants were included for review. At study level, the majority of comparisons did not reveal significant differences between dextrose prolotherapy and no treatment (or placebo) regarding pain control. The meta-analysis showed dextrose prolotherapy was effective in improving activity only at immediate follow-up (i.e., 0-1 month) (standardized mean difference [SMD]: 0.98; 95% confidence interval [CI]: 0.40-1.50; I = 0%); and superior to corticosteroid injections only in pain reduction at short-term follow-up (i.e., 1-3 month) (SMD: 0.70; 95% CI: 0.14-1.27; I = 51%). No other significant SMDs were found in this analysis.

There is insufficient evidence to support the clinical benefits of dextrose prolotherapy in managing dense fibrous tissue injuries. More high-quality randomized controlled trials are warranted to establish the benefits of dextrose prolotherapy.

PROSPERO (CRD42019129044).

Botulinum toxin type A (BTX-A) have been recently administered to improve Diabetic neuropathies; however, the efficacy of this treatment for relieving pain in painful diabetic polyneuropathy (DPN) has not been studied yet. Herein, we investigated the efficacy of botulinum toxin A (BTX-A) on DPN.

This prospective, randomized, double-blind, controlled trial was performed in Imam Hossein Medical Center, pain clinic (Tehran, Iran). Diabetic patients (141 cases), between 40 and 70 years old with polyneuropathy in lower limbs were randomly assigned to one of these three groups: 1. Group D1 received 150 units of BTX-A in one foot and normal saline 0.9% in the other foot, 2. Group D2 received BTX-A 150 units in both feet, 3. Group N received normal saline 0.9% in both feet. All injections were performed intradermally using insulin syringes in 20 different points of foot. Visual analogue scale (VAS) and neuropathy pain scale (NPS) were used to compare the groups.

The improvement of VAS, pain intensity, sharp and hot sensation, sensitive and unpleasant sensation, deep and surface sensation was significant when comparing BTX-A and placebo groups. However, dull and cold sensations improvement (p = 0.114, and p = 0.653; respectively) did not show a significant difference between BTX-A injection and placebo groups. Furthermore, the percentage of changes after treatment indicated that sharp pain was improved more than other complaints (80%, 81%, and 37% for D1, D2, and N groups; respectively).

Intradermal administration of BTX-A was effective in improving VAS and all of the items of NPS in patients with diabetic polyneuropathy, except for dull and cold sensation.

To determine whether dextrose prolotherapy offers clinical benefits in patients with shoulder pain and bursitis.

Double-blinded, randomized controlled trial.

Outpatient rehabilitation department of a single medical center.

Patients (N=50) who had received a diagnosis of shoulder pain and bursitis through clinical tests and ultrasound examination.

Participants were randomly assigned to the 15% dextrose injection (D15W) group or the placebo group to receive either D15W or normal saline injection, respectively. All participants received ultrasound-guidance bursal injection every 2 weeks for a total of 3 injections.

The primary outcome was maximal pain level while performing activities. The secondary outcomes included resting pain level, function and disability assessment results, and ultrasonographic parameters. Participants were followed up for 3 months after completion of the injection course.

No significant differences in baseline characteristics were observed between the D15W and placebo groups. Significant time effects were observed for all outcome parameters (all P<.05); however, time × group effects were nonsignificant for all outcomes, except for tissue elasticity (P=.026).

Supporting evidence is insufficient regarding the clinical benefits of 15% dextrose bursal injection administered through 3 sessions in patients with chronic shoulder pain and bursitis. The findings indicate that these injections may increase the tissue stiffness of the supraspinatus tendon, as indicated by elastography assessment results, but further research is required to determine the nature of such changes in elastography findings.

Image-guided interventional procedures around the shoulder are commonly performed in clinical practice, although evidence regarding their effectiveness is scarce. We report the results of a Delphi method review of evidence on literature published on image-guided interventional procedures around the shoulder with a list of clinical indications.

Forty-five experts in image-guided musculoskeletal procedures from the ESSR participated in a consensus study using the Delphic method. Peer-reviewed papers regarding interventional procedures around the shoulder up to September 2018 were scored according to the Oxford Centre for Evidence-based Medicine levels of evidence. Statements on clinical indications were constructed. Consensus was considered as strong if more than 95% of experts agreed and as broad if more than 80% agreed.

A total of 20 statements were drafted, and 5 reached the highest level of evidence. There were 10 statements about tendon procedures, 6 about intra-articular procedures, and 4 about intrabursal injections. Strong consensus was obtained in 16 of them (80%), while 4 received broad consensus (20%).

Literature evidence on image-guided interventional procedures around the shoulder is limited. A strong consensus has been reached for 80% of statements. The ESSR recommends further research to potentially influence treatment options, patient outcomes, and social impact.

• Expert consensus produced a list of 20 evidence-based statements on clinical indications of image-guided interventional procedures around the shoulder. • The highest level of evidence was reached for five statements. • Strong consensus was obtained for 16 statements (80%), while 4 received broad consensus (20%).