New Nontraditional Ways to Treat Shoulder Pain

In this article, Dr. Theodore Blaine from Yale University School of Medicine brings us up-to-date on the latest in biologic treatments for shoulder pain. In particular, Dr. Blaine's area of expertise is the nontraditional treatment of shoulder arthritis. Nonsurgical, biologic treatment includes the use of medications, injections, cytokines, growth factors, platelet rich plasma, and stem cells. Here's a brief summary of recent developments in this area.

Medications: Physicians continue to rely on the old standbys in this area (acetaminophen or Tylenol, nonsteroidal antiinflammatories, and corticosteroids). Studies show that acetaminophen remains a popular choice for relief of mild shoulder pain due to osteoarthritis. Acetaminophen combined with Tramadol (Ultram), a more narcotic-like (stronger pain reliever) is used for patients with severe pain.

Nonsteroidal antiinflammatory drugs (NSAIDs) offer better pain relief than acetaminophen but newer studies have shown some problems with rotator cuff tendon healing when taking these medications. NSAIDs seem to help most by improving patients' ability to sleep and participate in physical therapy.

The use of oral (by mouth) steroids has fallen out of favor as studies show these medications provide only very short-term improvement in pain. Comparing groups of patients with shoulder pain taking steroids versus a placebo -- 12 weeks later, the placebo group actually had better results.

Injections: Likewise, corticosteroid injections directly into a joint offer short-term pain relief, which in turn, gives patients better motion and function. There is some evidence that corticosteroids also reduce inflammation and may work better than nonsteroidal antiinflammatory drugs (NSAIDs) for some causes of shoulder pain (e.g., rotator cuff disease, bursitis).

Other types of injections include hyaluronate and botulinum toxin or BOTOX. Hyaluronate increases fluid within the joint and makes motion smoother and easier with less compression and shearing of the joint surfaces. Studies done by Dr. Blaine show that hyaluronate is a safe and effective treatment for shoulder osteoarthritis that has not responded to more traditional treatment with medications. The FDA has not yet approved hyaluronate for treatment of shoulder osteoarthritis.

BOTOX actually paralyzes muscles but also stops pain at the nerve endings. Although BOTOX has not been approved for use with shoulder pain, there appears to be little risk in using this injection therapy. This may be another nontraditional treatment technique for future use.

Cytokines: Cytokines are regulating molecules in the immune system and may assist in reducing inflammation. Cytokines may have a future role in providing a better solution to shoulder pain without the adverse effects of medications and injections. Areas of research right now are focused on the use of cytokines with patients who have bursitis and those with diabetes and rotator cuff disease.

Growth factors: Another possible way to encourage faster, better healing after rotator cuff surgery may be in the use of growth factors. Type I and Type III collagen fibers must be replaced and growth factors such as bone morphogenetic proteins (BMPs), platelet-derived growth factor (PDGF), basic fibroblast growth factor (bFGF), and transforming growth factor-B (TGF-B) may turn out to be the right tool for this. Studies are only in animal models at this time.

Platelet-Rich Plasma. Much has already been studied and written about regarding the use of growth factors found in platelet-rich plasma (PRP taken from the patient's own blood). These growth factors may be able to aid in the repair of damaged soft tissues. Researchers are looking at various effects of PRP on rate of recurrent rotator cuff tears, tendon and muscle strength after treatment, effects on small versus large rotator cuff tears, and long-term results.

Stem Cells. Stem cells are the basic cells that can turn into any other kind of cell, including tendon. Utilizing stem cells to repair damaged tendons by the regeneration of tendon cells in rats and rabbits have shown mixed results. This is another biologic treatment tool that may yet be used but much more research is needed before the hows and whats of tendon regeneration via stem cells is ready for human use.

In summary, Dr. Blaine's work of bringing more tools to the conservative side of treatment for shoulder pain from arthritis is important as more and more younger people are affected by this problem. Pain relief and improved function are the short-term goals.

Finding ways to enhance healing of the rotator cuff (especially after surgical repair) remain a challenge for future research studies. Biologic agents such as growth factors, stem cells, pharmacologic agents (or some combination of these) may have a central role in future treatments for shoulder pain.

Reference: 

Arya Varthi, et al. Biologic Treatments for Shoulder Pain. In Current Orthopaedic Practice. July/August 2013. Vol. 24. No. 4. Pp. 360-364.

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