Viscosupplementation for Shoulder Arthritis: What You Need to Know

Viscosupplementation for Shoulder Pain

While all FDA-approved hyaluronic acid products are specifically indicated for knee osteoarthritis, some physicians use viscosupplementation off-label for shoulder arthritis. This guide explains what this means for patients considering HA injections for shoulder pain.

Important: Understanding Off-Label Use

What “Off-Label” Means

When a medication is used “off-label,” it means:

• The FDA has approved the drug for a different condition (in this case, knee OA)
• Doctors legally prescribe it for other uses based on clinical judgment
• Research may support the use, but formal FDA approval hasn’t been obtained
• Insurance coverage is typically not available

Why It’s Used for Shoulders

Physicians may recommend shoulder HA injections because:

• The shoulder joint has similar synovial fluid to the knee
• Early studies show promising results
• Some patients prefer it over cortisone’s potential side effects
• It may delay need for shoulder replacement surgery

Shoulder Anatomy and Arthritis

The Glenohumeral Joint

The main shoulder joint (glenohumeral) is where HA injections are given:

• Ball-and-socket joint (humerus + scapula)
• Surrounded by synovial membrane
• Contains synovial fluid (like the knee)
• Susceptible to osteoarthritis, especially with age or injury

How Shoulder OA Develops

Common causes include:

• Primary osteoarthritis - Age-related wear and tear
• Post-traumatic arthritis - Following fractures or dislocations
• Rotator cuff tear arthropathy - Arthritis from chronic rotator cuff damage
• Avascular necrosis - Loss of blood supply to the humeral head

What the Research Shows

Current Evidence

The evidence for shoulder viscosupplementation is limited but growing:

Why Evidence Is Limited

• Fewer large-scale studies compared to knee
• No FDA approval means less pharmaceutical research funding
• Shoulder anatomy is more complex
• Multiple conditions can cause shoulder pain

Promising Research

Recent studies suggest:

• HA may be as effective as cortisone for shoulder OA
• Longer-lasting relief compared to steroid injections
• Fewer potential side effects than repeated cortisone
• May be particularly helpful in early-stage arthritis

Who Might Be a Candidate

Potentially Appropriate Patients

• Glenohumeral osteoarthritis confirmed on X-ray
• Failed conservative treatment (PT, NSAIDs, activity modification)
• Not a surgical candidate or wants to delay surgery
• Previous cortisone with diminishing returns
• Willing to pay out-of-pocket (insurance usually doesn’t cover)

May NOT Be Appropriate

• Rotator cuff tears as primary problem
• Severe bone-on-bone arthritis
• Inflammatory arthritis (rheumatoid, etc.)
• Active infection or skin issues near shoulder
• Expecting insurance coverage

The Shoulder Injection Procedure

Key Differences from Knee

Importance of Imaging Guidance

For shoulder injections, imaging guidance is essential because:

• The joint space is smaller and deeper
• Multiple structures surround the joint
• Accuracy significantly impacts effectiveness
• Blind injections have higher miss rates

Guidance options include:

• Fluoroscopy (real-time X-ray) - Gold standard
• Ultrasound - Real-time, no radiation
• CT guidance - For complex cases

The Procedure

1. Positioning - Typically seated or lying down
2. Imaging setup - Fluoroscopy or ultrasound positioned
3. Skin preparation - Sterilization of injection site
4. Local anesthetic - Usually provided for comfort
5. Needle placement - Guided to joint space
6. Injection - HA delivered into glenohumeral joint
7. Post-procedure - Brief observation, then discharge

What to Expect

After the Injection

First 24-48 hours:

• Mild soreness at injection site
• Rest the shoulder (avoid overhead activities)
• Ice as needed for comfort
• Normal daily activities are fine

First 1-2 weeks:

• Gradual improvement in some patients
• Continue gentle range of motion
• Avoid heavy lifting or sports

Weeks 2-12:

• Progressive pain relief if responding
• Improved function and range of motion
• Return to normal activities

Realistic Expectations

Be aware that:

• Results are less predictable than for knee
• Not everyone responds to treatment
• Benefits may be shorter than knee injections (3-6 months)
• May need to try different brands if one doesn’t work
• No insurance coverage in most cases

Cost Considerations

Why Shoulder HA Is More Expensive

Typical Costs

• Medication: $300-$800 per injection
• Procedure fee: $200-$500
• Imaging guidance: $200-$500
• Total range: $800-$2,000 per injection

Questions to Ask About Cost

• Is the price all-inclusive or itemized?
• What imaging guidance is included?
• Are follow-up visits included?
• What is the refund policy if it doesn’t work?

Alternatives to Consider

Before choosing off-label shoulder HA, consider:

Covered Treatments

• Physical therapy - Usually covered, may be very effective
• Cortisone injections - Covered, provides temporary relief
• NSAIDs - Covered, good for mild-moderate symptoms
• Shoulder replacement - Covered when medically necessary

Other Options

• PRP injections - Also typically not covered
• Stem cell therapy - Experimental, not covered
• Activity modification - Free, often helpful
• Weight management - Reduces joint stress

Frequently Asked Questions

Will Medicare cover shoulder HA injections?

No, Medicare does not cover viscosupplementation for the shoulder because it’s not FDA-approved for this use.

Can my doctor prescribe it anyway?

Yes, doctors can legally prescribe FDA-approved medications for off-label uses based on their clinical judgment.

How does it compare to cortisone for shoulders?

Early research suggests HA may provide longer-lasting relief with fewer side effects, but cortisone remains the more established treatment with insurance coverage.

How many injections will I need?

This varies by product and protocol. Some doctors use single injections; others prefer a series of 3-5 weekly injections.

What if it doesn’t work?

If HA injections don’t provide relief, other options include additional physical therapy, cortisone injections, or surgical consultation.

Is it safe?

The safety profile for shoulder injections appears similar to knee injections. The main risks are temporary soreness, infection (rare), and allergic reaction (rare).

Making an Informed Decision

Questions to Ask Your Doctor

1. Have you performed many shoulder HA injections?
2. What outcomes have your patients experienced?
3. What imaging guidance do you use?
4. What brand do you recommend and why?
5. What’s the total cost including all fees?
6. What alternatives would you suggest?

Red Flags to Watch For

Be cautious if a provider:

• Guarantees specific results
• Pressures you to decide immediately
• Doesn’t discuss insurance limitations upfront
• Won’t use imaging guidance
• Can’t explain their experience with this procedure

Looking for FDA-approved treatment options? Learn about viscosupplementation for knee arthritis or compare HA brands.