377- The Correlation Between Steroid Injections and Rotator Cuff Tears

Welcome to the Evidence Based Chiropractor where each week we deliver the latest chiropractic research and marketing strategies all in the time it takes to get to your office. Now, here's your host, Dr. Jeff Langmaid.

Hello and welcome to the Evidence Based Chiropractor. I AM your host, Dr. Jeff Langmaid. On today's episode we're talking about shoulders and steroid injections. A positive correlation between steroid injections and cuff tendon tears. A cohort study using a clinical database. This is a new study and if you are a doc who takes care of extremities or we know how intertwined shoulder issues are with thoracic spine issues, with cervical spine issues, basically, if you're a chiropractor, you're listening to this podcast. You are gonna get a lot out of today's episode and great practical information to advise your patients about some of the challenges that I can guarantee you they are totally unaware of regarding steroid injections in the shoulder. Before we get started, I wanna say a few words about Patient Pilot by the Smart Chiropractor. Reactivations are where it's at. We are seeing 26 reactivations per month with our average member. We work with over 300 practices around the world. We send about a million.2 emails per month and we can generate reactivations for your practice. We have a 3x ROI guarantee. If all of that sounds interesting to you, head over to thesmartchiropractor.com and schedule a demo 15 minutes of time. Let us ask you some questions. Walk through we what Patient Pilot does, how it can impact your practice and we'll see if it's a great fit to help you reach your goals this year. You can schedule that free complimentary demo 15 minutes of time@the smartchiropractor.com and I'll drop a link down below. But as I said at the top of the episode, we're talking research. On today's show. A study that came out in 2022 in the international Journal of Environmental Research and Public Health. That's a new one for me. And the title of the article. We'll link it and drop it in the show notes a positive correlation between steroid injections and cuff tendon tears. A cohort study using a clinical database. So shoulder pain is one of the top reasons that people visit our practices as chiropractors. It is also one of the top reasons people visit a primary care physician practice and it makes up over 1.2% of general practice visits. Ranking it only behind neck and back pain are some of the top reasons. So that's a big deal. There's a lot of people dealing with shoulder pain. We've highlighted some really great studies on past episodes regarding correlation between thoracic spine issues and shoulder issues, correlation between cervical spine issues and shoulder issues. This one's really targeting what's going on with those steroid injections. So shoulder pain does account for, for 7 to 34% of the entire population. So people are struggling with this. And 21% older than 70 years old are struggling with shoulder pain. So this is something I know we see all the time. And shoulders are dynamic, right. They're one of the, I guess, most unstable, so to speak, joints in our body. And the irony is, of course, when it hurts, people don't want to move it. And what's the number one thing you need to do to heal is to move it right. So you can end up with frozen shoulder amongst a host of other challenges if you're not getting in there with movement based active rehab. So that's where movement based care, as we highlight week in and week out on this podcast, so critical, but people are looking other directions. I'm sure that you've had patients within the last month, if you have pretty good volume in your practice that have had shoulder issues that might be considering having injections. So let's first, before we get there, talk about what shoulder pain can be attributed to. There's many things. It could be structural issues with the rotator cuff, tendon, bursa bone and joint. It could be functional aspects, impingement syndromes, adhesive capsulitis. And there also can be referred pain from visceral or adjacent organs. So all of this can contribute, which is why having great assessment tools, a great understanding of the anatomy, and certainly going through a thorough examination and history critical to be able to understand, well, what's going on, because you got to understand what's going on to be able to help in the best way possible. Now if somebody's going through shoulder pain and they're not taking care of it, we talked about things like frozen shoulder adhesive capsulitis that can happen, but this can also cause a tremendous amount of physical and mental challenges and it profoundly increases socioeconomic burdens, similar in many ways to what goes on with spine pain. So this really is just think about it pragmatically, pretty much everybody, whether you're on a computer, whether you're working on a truck, whether you're working in a warehouse, you're using your arms all day, every day. And probably many of your patients are as well, pretty much regardless of what their occupation is. And if they have a position that is, you know, they're using their hands, their wrists, their shoulders, their arms, all day, every day. Well, by nature of having that position where you're unable to move your shoulder due to pain, that can create a huge challenge. So pain, being able to get in there, get things moving, reduce pain and improve quality of life, critically important. So this paper highlights the fact that attention recently has been focused on some of these real serious negative effects that local steroids have on tendons. They highlight some animal studies that show steroids can degrade collagen, decrease fibroblast proliferation, increase inflammation and cytotoxicity, and interfere with the biomechanics of tendons. Those were in animal studies. Now in human tendon studies, we've seen collagen degradation, we've seen fibroblast aging, we've seen exotoxicity and impaired collagen healing in those human tendons. So those are not good things when you're trying to heal from an injury to the shoulder. And this is one of those big things. I've highlighted it a few times on this show and I just want to take a moment and highlight it again. And, you know, I want to be careful because I don't want to go overboard and overstate things. But I find that we don't take these things seriously enough in many cases. And that is steroid injections are, generally speaking, except for rare occasions, not good. You know, they're not, you know, somebody gets one before a professional gets it before a basketball game to be able to get out there and play. There's a trade off for that, you know, and there's a reason why it's not used then in the rehab. Right? Because you're just using it to be able to get that relief for a very short amount of time if you're in acute pain, to be able to make, you know, $800,000 playing a single basketball game as a professional basketball player. The fact that people are, you know, people who are involved in labor, people who are involved in really long term activities that require them to use the tendons and the body parts that they're getting injected, it just makes no sense. You have to look towards movement based care. That was an awkward way to describe it. But what I mean by that is there's negative ramifications when steroids are happening, serious negative ramifications in general. It destroys joints over time. And we've all had patients that are, I'm perfectly fine when I get my three epidural steroid injections per year and come to you for maintenance. Now that might be true for them, but in their mind. But can you wean them off it? We see increased fracture rates when epidural steroid injections are given. Basically, they've been pulled out of pretty much all guidelines except in abject acute pain where you need to kind of get over that hump just to get moving. Right? So somebody that's in absolutely abject pain, they can't do any movement based therapy, any movement based care. An injection can sometimes help kickstart that process. But these things aren't meant to be lived on. They are not a solution. As a matter of fact, they inhibit the healing process substantially. Now, can they provide pain relief? Yes, that is what they are good for. Exceptionally short term pain relief they can do. And with that comes the other side of the coin. That is, it is not a treatment option. It does not provide healing. As a matter of fact, it causes advanced challenges down the road that stack up the more often you get them. So, so all of that's really important for people to understand, not based upon fear, but based upon empowerment of knowing what's actually going on. So in this study, they had a total of 1,025 patients with shoulder diseases that were enrolled in a clinical database. Between 2013 and 2019, they had 205 patients that were treated with steroid injections and 820 patients who did not receive injections. And they were followed up for almost 50 months. So pretty long term follow up there, which is awesome. The, the mean age of the people in this study was 59.4 years old. So almost about 60 years old there, which mirrors general population. Now the overall incidence rate of a rotator cuff tear was 2.9%. Okay, that's not too bad. But let's dig a little deeper on that and then we'll see the real story. It's 9.8% for those who received steroid injections and 1.2% for for those who did not. That's a big swing. Almost 10% of the individuals who had a steroid injection ended up having a rotator cuff tear when only about 1% of those who did not receive an injection ended up having a tear. That is a big deal. That is a big delta and that is something everybody needs to be aware of before they get that shot. So there's been previous studies that showed steroid injections within six months of Surgery will increase the risk of a revision surgery. And a lot of this comes down to softening of the tendons by the injections. This was reported by Watson and it explains why patients with preoperative injections were prone to re tear after that surgical fixation. Additionally, there's a paper by Ramirez that reported an incident rate of 17% for full thickness tendon tears in patients receiving steroid injections at 12 weeks. That is a lot of people. That's nearly a 1 in 5 opportunity if you get the steroid injection that you may going in and having a significant tear. Now most people are of course, think about it. Let's take off our conservative care, our chiropractor hats where it's like, golly, this is pretty damning evidence and I would agree, but people are just looking for relief. I mean, that's the gist of it, right? When somebody's in abject shoulder pain and they don't know what to do and their doctor's like, here, let's do an injection. You'll pretty much be able to walk out of here and do everything you want to do. That sounds pretty great when you don't understand the other side of that. And quite frankly, the other side of this is never being explained. I mean, maybe one in a thousand times, but nobody's being actually informed about what's going on. They're saying, hey, let's do an injection. You can walk out of here feeling great. That's the first step. Great doc, let's do it. So it's our job to be able to tell this story. Not to scare people into not having something done, but to help them really understand that's not a long term solution. It doesn't fix the problem. Now, if you want to get out of pain short term, it can be a good option on occasion, but it also can lead to advanced challenges down the road. The best way to take care of this might be a little slower than you want, but with proper movement, with your proper engagement, by doing some of the exercises we're doing at home, by getting in and mobilizing it in the practice and taking care of inflammation, you're going to have far better long term results. And yeah, you're going to get out of pain too. It might take a little bit longer than the instantaneous relief of an injection, but you're going to be so much better in the long run. And of course there are exceptions to this rule, but it's important to be able to have those conversations. Now, what were the conclusions in this Study steroid injections on the shoulder were associated with an increased risk of tear by 7.4 times with the meantime to onset 39 months compared to non injection. The incidence of tearing was elevated 3.25 times when having concurrent chronic liver disease and almost two and a half times with a smoking habit. So the liver one was super weird. And they kind of highlight that in the study saying, that's odd, we didn't expect that. But people with liver disease tend to have with steroid injections and they kind of highlight some of how it might happen. It's a little esoteric, but that's what they found in this study. Smoking one makes total sense, right? A 2.5 times higher if you're a smoker to have those complications. I think you're gonna see that pretty much with almost about anything, you know, Smoking certainly does not enhance the healing process, that's for sure. And most of the time it leads to greater challenges down the road. So I think there's a lot of great information in this study highlighting the challenges associated with steroid injections. That's not to say they should be illegal and never be done, but I think they're being done quite more than they need to or should to be or should be done based upon the conversations that the doctors are having, basically just guiding people right to it. And again, that's where I'm gonna say our job is to be able to fully educate one, is to understand what's going on out there, what the research says, so that we can intelligently speak to this when our patients have questions, or if your patient mentions it, being able to have an accurate conversation that doesn't involve, don't do that. That's not enough context for somebody to make a good decision. One doc says I should, one doc says I shouldn't. That happens all the time. And normally they're going to go with who they trust more. And quite often, you know, for better or worse, they're going to go with the orthopedic specialist, quote, unquote, who's saying I should get the injection, right? So being able to really break this down in a meaningful way is going to lend to the rapport and trust you build with the patient. It's also going to lend to them being able to actually make a better decision. And again, that sounds wildly different depending upon the patient presentation, depending upon your relationship, depending upon what's going on. But I think that at the base, base level, it's really important to be able to accurately let them know, hey, injections can provide short term pain relief on occasion, but it can provide long term challenges because you have such a greater risk for tearing that tendon. So our goal is to be able to use movement, which you're gonna have to do one way or the other to decrease the pain, to increase the functional ability and to give you the best, best fix quote unquote in healing long term that doesn't require all of those side effects that you can expect with an injection. So that's, that's you're taking it at a high level. But you can specify that of course for each individual patient in your practice. But great information, great study. I will link it down below. 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