Efficacy of hyaluronate injections in rotator cuff disorders: a level-I meta-analysis

Background: Rotator cuff disease is the most common cause of shoulder pain and weakness. Conservative treatment is the first choice of shoulder pain management. Viscosupplementation of hyaluronic acid (HA) seems to be effective for management of tendon disorders. The objective of this study was to evaluate the scientific evidence reported in literature according to HA shoulder injection in rotator cuff disorders treatment. Methods: An English-language systematic literature search was performed by two independent researchers; data sources included the following databases: MEDLINE, Embase, CINAHL, Google scholar web, Ovid database, Physiotherapy Evidence Database (PEDro), and the Cochrane Library. We performed a broad research for relevant study up to February 2017. Articles were included if they reported data on clinical and functional outcomes in patients who had undergone HA injection for management of rotator cuff pathology compared to placebo, corticosteroid injection and/or physical therapies. Methodological quality was assessed with the PEDro rating scale. The outcomes were improvement of symptoms (assessed by VAS scale) and shoulder function (assessed through DASH and ASES Score). Results: 5 RCTs studies (990 patients) were pooled in the Meta-analysis. The PEDro rating scale ranged from 2 to 8. Two studies compared HA injection with corticosteroid injections, patients were injected once a week for three weeks. Four studies compared HA injection with placebo injection, of which two used 3 weekly injections and two used 5 weekly injections. Significant difference was found in pain reduction between HA and placebo group at 26 weeks follow-up (MD= -0.51, 95% CI -0.96 to -0.07), p=0.02. Conclusion: HA injections might be a valuable safe alternative to other conservative methods for the treatment of rotator cuff disorders. Nowadays, few and low quality randomized controlled trials have been published. Therefore, to reach an overall conclusion about the effect of HA injection in rotator cuff we need more high quality studies. Level of evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence. Study design: Meta-analysi