Comparison of the efficacy of hyaluronic acid vs corticosteroids, platelet-rich plasma, and physical therapy in chronic shoulder pain:: a systematic review and a frequentist network metanalysis.

OBJECTIVE: To compare the effectiveness of injected low- and high-molecular-weight hyaluronic acid (HA-LMW, HA-HMW) vs corticosteroids (CCS), placebo- or physical therapy (PT), on pain at rest (Prest), at night (Pnight), and during activity (Pact), range of motion (ROM), functional status (FS), and quality of life (QoL) in patients with chronic Sp, at 3 (3mo) and 6 months (6mo) follow-up. DATA SOURCES: A systematic literature search was conducted through October 2024 across MEDLINE, Embase, and Cochrane CENTRAL. STUDY SELECTION: Fourteen studies were included: 12 randomized controlled trials and 2 prospective cohort studies that compared at least two of the treatments of interest in adults with chronic shoulder pain (Sp). DATA EXTRACTION: Two reviewers independently extracted data related to the outcomes. DATA SYNTHESIS: A frequentist network meta-analysis with mean differences (MD) and standardized mean differences (SMD) was performed; p<0.05 was statistically significant. PT reduced Prest compared to HA-HMW (MD = -3.02, p<0.01 at 3mo; MD = -2.08, p<0.01 at 6mo) and HA-LMW (MD = -1.95, p<0.01 at 6mo) in tendinopathy. PT showed greater reduction than both HA formulations in Pnight and Pact at 6mo in tendinopathy. No differences were observed between HA-HMW and HA-LMW for pain outcomes considering shoulder different diseases. HA improved adduction and internal rotation at 3mo considering shoulder different disease; PT was superior for flexion and external rotation at 6mo in tendinopathy. Stratified by pathology, HA-HMW showed moderate efficacy in adhesive capsulitis. HA-HMW improved FS compared to HA-LMW at 3mo. CCS improved abduction in shoulder disease due to different causes. CONCLUSIONS: PT provides greater pain control for Sptendinopathy, particularly for Prest, Pnight, and Pact at both 3mo and 6mo. HA may contribute to improved QoL and specific ROM parameters. Further high-quality studies are required to consolidate these findings.