Houston Methodist. Leading Medicine

Shoulder FAQ

Question:

I've had two steroid injections into my shoulder for a frozen shoulder. Nothing happened that I could tell. Someone suggested I try prolotherapy. Someone else said to ask about hyaluronic acid. Would you recommend one over the other? What about for me?

Answer:

There are two separate schools of thought regarding treatment for adhesive capsulitis. Some experts suggest a home-based approach because eventually the problem corrects itself. Patients use pain relievers, moist heat, and simple exercises to keep the joint moving. Others recommend direct treatment to make sure patients regain normal motion and function. Most experts agree that severe painful limitations of motion should be treated by a physical therapist. For patients with persistent pain, pain-relieving medications and steroid injections are commonly used in addition to physical therapy. But steroid injections have some disadvantages and some patients either don't want them or can't tolerate them. That's when hyaluronic injections may be used instead. Hyaluronic acid is a normal part of the matrix that makes up cartilage. It has two distinct properties that make it so important for smooth joint motion. It is both viscous (slippery) and elastic. The viscosity allows the tissue to release and spread out energy. The elasticity allows for temporary energy storage. Together, these two properties protect the joint, help provide joint gliding action (especially during slow movement), and act as a shock absorber during faster movements. Some experts think hyaluronic acid (HA) injected into the shoulder has some additional benefits. They suggest that the HA reduces inflammation of the synovium (lubricating fluid inside the joint). It also has a direct effect on the pressure inside the joint to separate the joint capsule where it is stuck together. Hyaluronic acid may be protective of the joint cartilage and prevent the formation of adhesions that keep the capsule from the smooth gliding action needed for normal shoulder motion. The question naturally arises -- which works better: steroid or hyaluronic acid injections? In your case, you are also wondering about trying prolotherapy as well. Prolotherapy involves injecting a group of substances into the joint that will stimulate an inflammatory reaction. The idea is to restart the body's natural healing process that got interrupted, which may be why the joint froze up in the first place. We don't know of any studies comparing steroid injection to prolotherapy (or comparing either of those treatments to hyaluronic acid). However, the first study comparing steroid injection to hyaluronic acid injection has been published. The authors of the study divided 90 patients with adhesive capsulitis into two groups. The first group received a series of three steroid injections (spread out over six weeks' time) into the shoulder. The second group was injected with hyaluronic acid with the same frequency (one injection every two weeks for a total of three injections over six weeks' time). Ultrasound (instead of the usual fluoroscopy) was used to guide the needle into the joint. The main advantage of ultrasound over fluoroscopy is that it doesn't expose the patient to unnecessary radiation. That is important when using a series of injections with the potential for repeated radiation exposure. Results were measured using pain intensity, shoulder joint motion, and function. Everyone in both groups was evaluated using these measures before treatment and again two weeks and six weeks after treatment. They didn't find much difference in outcomes between the two treatment techniques. Everyone in both groups had less pain, better motion, and improved function. These improvements were observed at the two week follow-up and maintained through the six-week check-up. The only difference was greater passive external shoulder rotation with the hyaluronic acid injections. This might have occurred because the pressure from the hyaluronic acid opened up the joint space, which is needed to increase external rotation. The authors concluded by saying that hyaluronic acid injections delivered with careful placement using ultrasound may be just as effective as steroid injections. In fact, there may be some added advantages. The patients receiving hyaluronic injection via ultrasound are not exposed to radiation. They are not affected by the potential negative consequences of steroids (e.g., thinning and weakening of the soft tissues, skin color change). They even get some extra rotational motion. For patients who cannot tolerate steroid injections (or who don't want them), hyaluronic acid injection may be a good alternative treatment approach. Likewise, patients with other problems that affect the soft tissues such as diabetes, hyaluronic acid injections may be a better choice. If you have already started with steroid injections, your surgeon may advise you to finish the third injection before considering a different treatment approach. The effect of one or more hyaluronic acid injections following the two steroid injections you have already had are unknown. Ki Deok Park, MD, et al. Treatment Effects of Ultrasound-Guided Capsular Distention with Hyaluronic Acid in Adhesive Capsulitis of the Shoulder. In Archives of Physical Medicine and Rehabilitation. February 2013. Vol. 94. No. 2. Pp. 264-270.

*Disclaimer:* The information contained herein is compiled from a variety of sources. It may not be complete or timely. It does not cover all diseases, physical conditions, ailments or treatments. The information should NOT be used in place of visit with your healthcare provider, nor should you disregard the advice of your health care provider because of any information you read in this topic.
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