Ross Hauser, MD, Danielle Matias, PA-C, Demi Foster, APRN

At our clinic, we have provided more than 30 years of service to patients seeking non-surgical options to get them back to their sport. In this article, we will show our research and research of other clinicians in offering non-surgical solutions to “Swimmer’s Shoulder.”

Part of the reason for arthroscopic surgical failure of subacromial impingement is that it does not properly address the problems of hypermobility and shoulder instability. Possibly, because you are removing tissue in the shoulder during surgical procedures, the problem of instability becomes worse as shoulder ligaments, the connective tissue designed to keep shoulder bones in place, are compromised and weakened.

When the problem of subacromial shoulder pain is not inflammation, but instability

Our clinic has published numerous studies on the problems of shoulder joint instability and inflammation. Some of this research is summarized below. The simple idea is that instability causes inflammation. If you do not correct the instability, you can not correct the inflammation. To treat the problems of the swimmer’s shoulder, in our opinion, the swimmer must treat the problems of shoulder instability caused by ligament laxity.

The problem of how to deal with this instability was reflected in a study from the Hospital for Special Surgery, published in 2018 in the journal Current Reviews in Musculoskeletal Medicine. (1)

“Swimmers may develop increased shoulder laxity over time due to repetitive use. Such excessive laxity can decrease passive shoulder stability and lead to rotator cuff muscle overload, fatigue, and subsequent injury in order to properly control the translation of the humeral head (the movement of the shoulder).

• Generalized laxity can be present in up to 62% of swimmers, while a moderate degree of multi-directional instability can be present in the majority.
• Laxity in swimmers can be due to a combination of underlying inherent anatomical factors as well as repetitive overhead activity.
• The role of excessive laxity and muscle imbalance is crucial in the swimmer’s shoulder and should be well understood since they are the primary target of the training and rehabilitation program.”

Comparing cortisone and prolotherapy

A October 2023 paper in the American Journal of Physical Medicine & Rehabilitation (1) compared the treatment effectiveness of subacromial steroid injections and dextrose prolotherapy for chronic subacromial bursitis patients. The study concluded, “Both hypertonic dextrose prolotherapy and steroid injections can provide short-term improvements of pain and disability among chronic subacromial bursitis patients. Moreover, steroid injections showed better effectiveness than hypertonic dextrose prolotherapy in ameliorating pain and improving function.”

In this study, the steroid injection did better at 12 weeks after treatment than Prolotherapy. As written many times, Prolotherapy, for most people, is best given as a repeat course. At the 4 – 6 week interval. It is interesting to note that Prolotherapy’s effect could suggest a rebuilding of supporting tissue, whereas the steroid worked to reduce inflammation.

There were 54 patients enrolled in this double-blind randomized controlled trial. The Shoulder Pain and Disability Index and visual analog scale were the primary outcomes. (Pain and function before and after were assessed through a questionnaire).

• Results: Pain reduction.
  • The 26 patients in the steroid group exhibited significant visual analog scale score (pain reduction) improvements compared with baseline at weeks 2, 6, and 12. The dextrose prolotherapy group of 28 patients exhibited visual analog scale score improvements at weeks 6 and 12.
• Results: Improved function.
  • The steroid group displayed significant Shoulder Pain and Disability Index score improvements (pain and function improvements) compared with baseline at weeks 2, 6, and 12
  • The dextrose prolotherapy group exhibited significant score decreases (improvements) at weeks 2 and 6. Compared with the dextrose prolotherapy group, the steroid group demonstrated significantly greater decreases in visual analog scale scores at weeks 2 and 6; the steroid group showed significantly greater decreases in Shoulder Pain and Disability Index scores at weeks 2, 6, and 12.

In 2013, Medical University research teams in Turkey presented their findings on “The Effects of Prolotherapy in Patients With Subacromial Impingement Syndrome.” (2) These are the learning points of their research:

• Recent treatments for subacromial impingement syndrome are palliative (in other words, treating the symptom and not the cause). Dextrose injection, Prolotherapy, has emerged as a treatment option for chronic situations such as shoulder tendonitis and shoulder bursitis.
• The aim of the study is to investigate the effects of dextrose injection in patients with chronic shoulder pain caused by subacromial impingement syndrome.

In this single-center, randomized, placebo-controlled, single-blind, prospective study, 80 patients with chronic subacromial impingement syndrome who met the study criteria received two dextrose injections in the affected shoulder at two-week intervals.

The patients were randomly assigned to two therapy groups: either dextrose or another control (lidocaine) group.

The injections were repeated two times with two weeks between injections.

• Clinical assessments included measurement of:
  • range of motion (ROM),
  • pain assessment
  • shoulder functions and daily living activities
  • Magnetic resonance imaging (MRI) evaluation was conducted before the first injection and compared with MRIs taken again on the third month following the second injection.

Results:  The study demonstrated significant improvements in function and pain in both injection groups. Shoulder flexion, abduction, internal, and external rotations showed significant improvements in both groups in the first 3 months. While the range of shoulder flexion did not improve in the control group during the last three months, this range of motion continued to improve significantly in the Prolotherapy treatment group over the same period.

Again, we want to point out here that the patients received benefits from only two injections.

Caring Medical Research

Ross Hauser, MD, discusses the Prolotherapy treatment results that were published a few years ago.

In our research, published in Clinical Medicine Insights: Arthritis and Musculoskeletal Disorders, (4) Ross Hauser, MD, and Danielle R. Steilen-Matias, MMS, PA-C  contributed to findings suggesting Dextrose Prolotherapy has been able to reduce pain and disability of traumatic and nontraumatic rotator cuff conditions.

• Research revealed that treatment of moderate to severe rotator cuff tendinopathy due to injury with injections of hypertonic dextrose on painful entheses (the ligament and tendon attachments to the bone) resulted in superior long-term pain improvement and patient satisfaction compared with blinded saline injection over painful entheses, with intermediate results for entheses injection with saline.
• In a retrospective case-control study, dextrose Prolotherapy improved pain, disability, isometric strength, and shoulder active range of motion in patients with refractory chronic non-traumatic rotator cuff disease.

Related articles and more reading

Platelet Rich Plasma Therapy and shoulder impingement

Platelet Rich Plasma Therapy and shoulder impingement

References

1 De Martino I, Rodeo SA. The swimmer’s shoulder: multi-directional instability. Current reviews in musculoskeletal medicine. 2018 Jun;11(2):167-71. [Google Scholar]
2 Lin LC, Lee YH, Chen YW, Hsu TH, Vitoonpong T, Liou TH, Huang SW. Comparison Clinical Effects of Hypertonic Dextrose and Steroid Injections on Chronic Subacromial Bursitis: A Double-Blind Randomized Controlled Trial. American journal of physical medicine & rehabilitation. 2023 Mar 4:10-97. [Google Scholar]
3 Hannan EA, Gulseren Sr A, Hysenaj N. The Effects of Prolotherapy in Patients With Subacromial Impingement Syndrome. In ARTHRITIS AND RHEUMATISM 2013 Oct 1 (Vol. 65, pp. S461-S462). 111 RIVER ST, HOBOKEN 07030-5774, NJ USA: WILEY-BLACKWELL. [Google Scholar]
4 Hauser RA, Lackner JB, Steilen-Matias D, Harris DK. A systematic review of dextrose prolotherapy for chronic musculoskeletal pain. Clinical Medicine Insights: Arthritis and Musculoskeletal Disorders. 2016 Jan;9:CMAMD-S39160. [Google Scholar]