BACKGROUND:
Corticosteroid injections have been widely used for reducing shoulder pain. However, catastrophic complications induced by corticosteroid such as infections and tendon degeneration have made surgeons hesitant to use a corticosteroid injection as a pain control modality, especially during the postoperative recovery phase.
PURPOSE:
To determine the effectiveness and safety of a subacromial corticosteroid injection for persistent pain control during the recovery period and to analyze the factors causing persistent pain after arthroscopic rotator cuff repair.
STUDY DESIGN:
Cohort study; Level of evidence, 3.
METHODS:
A total of 458 patients who underwent arthroscopic rotator cuff repair were included in this study. Patient-specific parameters, tear size and pattern, and pain intensity were reviewed. Seventy-two patients were administered a postoperative subacromial corticosteroid injection under ultrasound guidance. The corticosteroid injection was administered to patients who awakened overnight because of constant severe shoulder pain or whose pain was exacerbated at the time of rehabilitation exercises within 8 weeks after surgery. Pain intensity, patient satisfaction, and functional outcomes using the American Shoulder and Elbow Surgeons (ASES) and Constant scores were compared between the patients with and without a subacromial corticosteroid injection. The retear rate was evaluated with magnetic resonance imaging at 6 months postoperatively.
RESULTS:
In patients with an injection, the mean (±SD) visual analog scale for pain (pVAS) score was 7.7 ± 1.2 at the time of the injection. This significantly decreased to 2.3 ± 1.4 at the end of the first month after the injection, demonstrating a 70.2% reduction in pain (P < .01). At 3 months after the injection, the mean pVAS score was 1.2 ± 1.8. Functional outcomes at final follow-up showed no significant differences between patients with and without an injection (ASES score: 90.1 ± 14.6 with injection, 91.9 ± 8.2 without injection [P = .91]; Constant score: 89.1 ± 12.9 with injection, 84.5 ± 13.0 without injection [P = .17]). Patients with an injection showed no significant increase in the retear rate (6.8% with injection, 18.4% without injection; P = .06). According to the tear pattern, L-shaped rotator cuff tears (41.8%) showed a higher occurrence of severe postoperative persistent pain. Preoperative shoulder stiffness was revealed as a predisposing factor for persistent pain (odds ratio, 0.2; P = .04).
CONCLUSION:
A subacromial corticosteroid injection can be considered as a useful and safe modality for the treatment of patients having severe persistent pain during the recovery phase after arthroscopic rotator cuff repair.
1. 수술 후, 통증 때문에 밤에 잠에서 깨거나 8주 이내 재활 동안에 통증 심해 지는 경우 inj.
2. medium 까지는 passive ROM 바로 시키고, 4주 brace. large to massive 는 6주까지 운동X, 6주 brace.
3. 둘 다 elastic band로 RC strenghtening은 3달 후에.
4. MRI 는 6개월 후
5. RC repair 후에 steroid inj. 하는게 통증 관리에 도움이 된다.
6. 수술 전 stiffness, L-shaped tear 가 통증과 관련된 인자.
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Paired t test ;
A comparison of injection-mediated pain reduction between the patients with and without an injection
Chi-square test ;
Clinical outcomes of the patients with and without an injection
Multivariate regression analysis ;
Factors influencing postoperative pain (with 95% CI). |
The subacromial bursa has an anatomic structure prone to frictional effects and thus easily develops subacromial bursitis secondary to a rotator cuff lesion. It is innervated by the suprascapular nerve posteriorly and the lateral pectoral nerve anteriorly, which contain dense free nerve endings. These nerve endings are responsible for the proprioception and nociception of the subacromial bursa and thus for pain perception in the presence of subacromial bursitis.* Therefore, surgeons should make every attempt to remove hypertrophic inflamed bursal tissues as much as possible during the arthroscopic procedure. We believe that the presence of remaining bursitis after limited bursectomy was more likely to cause postoperative persistent shoulder pain.
(*Ide K, Shirai Y, Ito H, Ito H. Sensory nerve supply in the human subacromial bursa. J Shoulder Elbow Surg. 1996;5(5):371-382.)
Limitation
....Furthermore, it was difficult to determine the exclusive effect of a subacromial corticosteroid injection because patients who complained of pain during follow-up were concomitantly given anti-inflammatory drugs. Moreover, this study did not have a control group with more severe pain that did not receive any pain control including corticosteroid injections. Therefore, it is not possible to determine how much of the pain reduction was caused by the steroid injection and how much may have spontaneously occurred as part of the normal progression of healing after surgery. However, observing the natural course of pain during the convalescence period or comparing a corticosteroid injection with other pain control methods was not allowed to be investigated for ethical reasons. ....