Image-guided versus blind glucocorticoid injection for shoulder pain

Comparison of ultrasound- vs. landmark-guided injections for musculoskeletal pain: an umbrella review

OBJECTIVE

This umbrella review synthesizes systematic reviews and meta-analyses to reach a conclusion concerning the overall effectiveness of ultrasound-guided vs landmark-guided injections for treating musculoskeletal pain.

DESIGN

Umbrella review.

METHODS

PubMed, EMBASE, MEDLINE, and Web of Science were searched for relevant systematic reviews and meta-analyses from inception to March 2024. Critical appraisal, data extraction, and synthesis were performed in accordance with the criteria for conducting an umbrella review.

RESULTS

Seventeen articles, comprising 4 systematic reviews and 13 meta-analyses, were included. Using the AMSTAR2 instrument for quality assessment, 3 articles were rated as high quality, 1 as moderate, 7 as low, and 6 as critically low. Generally, ultrasound-guided injections were found to be more accurate than landmark-guided injections, particularly in the shoulder joint, though the results for pain relief and functional outcomes varied. Ultrasound guidance was notably effective for injections into the bicipital groove, wrist, hip, and knee - yielding greater accuracy and improved pain management. Both ultrasound-guided and landmark-guided techniques showed low incidence of adverse effects.

CONCLUSION

This umbrella review offers an in-depth analysis of the comparative effectiveness of ultrasound-guided and landmark-guided injections across a range of musculoskeletal sites/conditions. The findings suggest that ultrasound-guided is a reliable method.

Ultrasound-guided versus palpation-guided platelet-rich plasma injection for the treatment of chronic lateral epicondylitis: A prospective, randomized study

OBJECTIVES

This study aims to compare the effectiveness of palpation-guided and ultrasound (US)-guided platelet-rich plasma (PRP) injections in patients with chronic lateral epicondylitis (LE).

PATIENTS AND METHODS

Between January 2021 and August 2021, a total of 60 patients (34 males, 26 females; mean age: 40.5±10.9 years; range, 22 to 64 years) diagnosed with chronic LE were included. The patients were randomly allocated to either the palpation-guided (n=30) or the US-guided injection group (n=30) before they received PRP injection. All patients were assessed using the Visual Analog Scale (VAS), Disabilities of the Arm, Shoulder and Hand (DASH) scale, and grip strength at baseline and at one, three, and six months after injection.

RESULTS

Baseline sociodemographic and clinical variables were statistically similar between two groups (p>0.05). The VAS and DASH scores improved significantly after the injection at each control, as well as grip strength in both groups (p<0.001). No statistically significant difference was found between the groups regarding VAS and DASH scores, and grip strength at one, three, and six months post-injection (p>0.05). No significant complication related to the injection was observed in any of the groups.

CONCLUSION

This study demonstrates that both palpation-guided and US-guided PRP injection protocols can improve clinical symptoms and functional parameters of patients with chronic LE.

Efficacy of Single Injection of Platelet-Rich Plasma in Shoulder Impingement Syndrome

Introduction

To analyze the change in Visual Analog Scale (VAS), QuickDASH score, and the range of motion at the shoulder joint following a single injection of platelet-rich plasma (PRP) in shoulder impingement syndrome.

Methods

Twenty patients (21 shoulders) of either sex above the age of 18 years with a clinical diagnosis of shoulder impingement having a positive shoulder impingement test (positive Hawkins-Kennedy impingement test and/or positive Neer's impingement sign), ultrasonographic confirmation of shoulder impingement, and a failure to respond to standard non-operative methods for a minimum period of four weeks were included in this prospective interventional study. PRP was injected at the proposed site. At three months after the injection, the changes in the VAS, QuickDASH score, and the range of motion at the shoulder joint were analyzed.

Results

There were significant changes in the VAS, QuickDASH score, and range of motion at the shoulder joint following a single injection of PRP.

Conclusions

Platelet-rich plasma (PRP) injection results in a significant decrease in pain and improvement in the range of motion and an overall excellent functional outcome in shoulder impingement syndrome. However, future studies with a bigger sample size and longer follow-up are needed.

Ultrasound-Guided Treatments for the Painful Shoulder

Shoulder pain is an extremely common condition. The painful shoulder may be the result of a wide spectrum of underlying pathological conditions, including calcific tendinopathy of the rotator cuff, subacromial-subdeltoid bursitis, acromioclavicular or glenohumeral arthritis, tenosynovitis of the long biceps tendon, rotator cuff lesions, and many other less common conditions. Ultrasound imaging is an effective tool for the diagnosis and also for the image guidance of treatment of the majority of these conditions. Several ultrasound-guided procedures are effective for pain relief, such as percutaneous irrigation, intra-bursal or intra-articular drugs injection, fluid aspiration, neural block. This review article aims to summarize and discuss the most common treatment possibilities with ultrasound guidance for the painful shoulder.

Orthopedic Surgeons' Views of Hyaluronic Acid Formulations in the Management of Knee Osteoarthritis: A Questionnaire-Based Cross-Sectional Study

Background and Objectives: Multiple hyaluronic acid (HA) products were approved and marketed to manage osteoarthritis (OA). Although these products are widely prescribed by orthopedic surgeons to manage OA, especially knee OA, the therapeutic value of these products is highly uncertain. Few studies with significant limitations in their designs have indicated positive outcomes among OA patients treated with HA; however, their results were inconclusive. Thus, we aimed to explore the therapeutic value of different HA products in alleviating knee OA pain and improving patients’ physical function from the orthopedic surgeons’ perspective. Materials and Methods: This was a questionnaire-based cross-sectional study in which practicing orthopedic surgeons in two countries (e.g., Saudi Arabia and Jordan) were invited to participate. The 10-item, newly developed questionnaire inquired about the respondents’ sociodemographic characteristics (e.g., age, gender, country, years of experience), and their opinions regarding the efficacy of HA products in the management of OA (e.g., efficacy in improving mobility and alleviating pain). Results: Out of the 200 orthopedic surgeons who were invited to participate, 122 (61%) filled out the questionnaire. Most of the respondents were from Saudi Arabia (58%), aged 35 to 55 years (68%), had at least 10 years of experience (69%), and male (98%). About 80% of the respondents reported prescribing HA, such as Hyalgan^®, Orthovisc^®, Hyalubrix^®, and Crespine Gel^®. About 66% of the respondents believed that HA was moderately to highly effective in managing knee OA, and 34% believed that HA was either ineffective or mildly effective. Pain at the site of injection (44.3%) and rash or local skin reactions (22.1%) were the most commonly reported adverse events. Conclusions: The variations in the formulation of different HA brands (e.g., molecular weight and cross-linking) did not seem to offer any therapeutic advantage. HA might have value in the management of knee OA; however, its value is highly uncertain and necessitates more well-designed studies to further examine its therapeutic value.

Image-Guided Versus Blind Corticosteroid Injections in Adults With Shoulder Pain: A Systematic Review and Meta-Analysis

The present study aimed to compare the clinical effects of image-guided versus blind steroid injection to treat shoulder pain, which is always debatable. An electronic search of credible databases was conducted for randomized controlled trials (RCTs) comparing image-guided versus blind steroid injections. The continuous data were pooled as mean difference (MD) or standardized mean difference (SMD), and dichotomous data were grouped as odds ratio (OR) with 95% confidence interval (CI). Sensitivity analysis and leave-one-out analysis were performed. The meta-analysis of 20 RCTs comprising 1136 patients favored image-guided injection based on the MD of the visual analog score (VAS) and shoulder function scores, measured between six weeks follow-up and baseline (MD=0.63, 95% CI [0.13, 1.12], p=0.01 and SMD=0.35, 95% CI [0.05, 0.65], p=0.02, respectively). Meta-analysis did not favor either group regarding the shoulder disability scores or side effects (MD=-2.18, 95% CI [-12.19, 7.83], p=0.67, and OR=0.40, 95% CI [0.14, 1.15], p=0.09, respectively). The image-guided approach was associated with significant improvement in pain and shoulder functionality. However, no significant difference was observed between the two approaches in terms of disability scores and side effects.

Image-guided glucocorticoid injection versus injection without image guidance for shoulder pain

BACKGROUND

Despite widespread use, our 2012 Cochrane review did not confirm that use of imaging to guide glucocorticoid injection for people with shoulder pain improves its efficacy.

OBJECTIVES

To update our review and assess the benefits and harms of image-guided glucocorticoid injection compared to non-image-guided injection for patients with shoulder pain.

SEARCH METHODS

We updated the search of the Cochrane Central Register of Controlled Trials (CENTRAL, via Ovid), MEDLINE (Ovid), Embase (Ovid) and clinicaltrials.gov to 15 Feb 2021, and the World Health Organisation International Clinical Trials Registry Platform (http://www.who.int/trialsearch/Default.aspx) to 06 July 2020. We also screened reference lists of retrieved review articles and trials to identify potentially relevant studies.

SELECTION CRITERIA

We included randomised or quasi-randomised controlled trials that compared image-guided glucocorticoid injection to injection without image guidance (either landmark-guided or intramuscular) injection in patients with shoulder pain (rotator cuff disease, adhesive capsulitis or mixed or undefined shoulder pain). Major outcomes were pain, function, proportion of participants with treatment success, quality of life, adverse events, serious adverse events and withdrawals due to adverse events. Minor outcomes were shoulder range of motion and proportion of participants requiring surgery or additional injections. There were no restrictions on language or date of publication.

DATA COLLECTION AND ANALYSIS

We used standard methodologic procedures expected by Cochrane.

MAIN RESULTS

Nineteen trials were included (1035 participants). Fourteen trials included participants with rotator cuff disease, four with adhesive capsulitis, and one with mixed or undefined shoulder pain. Trial size varied from 28 to 256 participants, most participants were female, mean age ranged between 31 and 60 years, and mean symptom duration varied from 2 to 23 months. Two trials were at low risk of bias for all criteria. The most notable sources of bias in the remaining trials included performance bias and detection bias. Moderate-certainty evidence (downgraded for bias) indicates that ultrasound-guided injection probably provides little or no clinically important benefits compared with injection without guidance with respect to pain (15 trials) or function (14 trials) at three to six weeks follow-up. It may not improve quality of life (2 trials, low-certainty evidence, downgraded due to potential for bias and imprecision) and we are uncertain about the effect of ultrasound-guided injection on participant-rated treatment success due to very low-certainty evidence (downgraded for bias, inconsistency and imprecision). Mean pain (scale range 0 to 10, higher scores indicate more pain) was 3.1 points with injection without image guidance and 0.5 points better (0.2 points better to 0.8 points better; 1003 participants, 15 trials) with an ultrasound-guided injection. This represents a slight difference for pain (0.5 to 1.0 points on a 0 to 10 scale). Mean function (scale range 0 to 100, higher scores indicate better function) was 68 points with injection without image guidance and 2.4 points better (0.2 points worse to 5.1 points better; 895 participants, 14 trials) with an ultrasound-guided injection. Mean quality of life (scale range 0 to 100, higher scores indicate better quality of life) was 65 with injection without image guidance and 2.8 points better (0.7 worse to 6.4 better; 220 participants, 2 trials) with an ultrasound-guided injection. In five trials (350 participants), 101/175 (or 606 per 1000) people in the ultrasound-guided group reported treatment success compared with 68/175 (or 389 per 1000) people in the group injected without image guidance (RR 1.56 (95% CI 0.89 to 2.75)), an absolute difference of 22% more reported success (4% fewer to 62% more). Low-certainty evidence (downgraded for bias and imprecision) indicates that ultrasound-guided injections may not reduce the risk of adverse events compared to injections without image guidance. In five trials (402 participants), 38/200 (or 181 per 1000) people in the ultrasound-guided group reported adverse events compared with 51/202 (or 252 per 1000) in the non-image-guided injection group (RR 0.72 (95% CI 0.4 to 1.28)), an absolute difference of 7% fewer adverse events (15% fewer to 7% more). Five trials reported that there were no serious adverse events. The remaining trials did not report serious adverse events. One trial reported that 1/53 (or 19 per 1000) in the injection without image guidance group and 0/53 in the ultrasound-guided group withdrew due to adverse events. Sensitivity analyses indicate that the effects for pain and function may have been influenced by selection bias, and the effects for function may have been influenced by detection bias. The test for subgroup differences indicated there were unlikely to be differences in pain and function across different shoulder conditions.

AUTHORS' CONCLUSIONS

Our updated review does not support use of image guidance for injections in the shoulder. Moderate-certainty evidence indicates that ultrasound-guided injection in the treatment of shoulder pain probably provides little or no benefit over injection without imaging in terms of pain or function and low-certainty evidence indicates there may be no difference in quality of life. We are uncertain if ultrasound-guided injection improves participant-rated treatment success, due to very low-certainty evidence. Low-certainty evidence also suggests ultrasound-guided injection may not reduce the risk of adverse events compared with non-image-guided injection. No serious adverse events were reported in any trial. The lack of significant benefit of image guidance over injection without image guidance to improve patient-relevant outcomes or reduce harms, suggests that any added cost of image guidance appears unjustified.

Cost-effectiveness of surgical treatments compared with early structured physiotherapy in secondary care for adults with primary frozen shoulder : an economic evaluation of the UK FROST trial

Aims

A pragmatic multicentre randomized controlled trial, UK FROzen Shoulder Trial (UK FROST), was conducted in the UK NHS comparing the cost-effectiveness of commonly used treatments for adults with primary frozen shoulder in secondary care.

Methods

A cost utility analysis from the NHS perspective was performed. Differences between manipulation under anaesthesia (MUA), arthroscopic capsular release (ACR), and early structured physiotherapy plus steroid injection (ESP) in costs (2018 GBP price base) and quality adjusted life years (QALYs) at one year were used to estimate the cost-effectiveness of the treatments using regression methods.

Results

ACR was £1,734 more costly than ESP ((95% confidence intervals (CIs) £1,529 to £1,938)) and £1,457 more costly than MUA (95% CI £1,283 to £1,632). MUA was £276 (95% CI £66 to £487) more expensive than ESP. Overall, ACR had worse QALYs compared with MUA (-0.0293; 95% CI -0.0616 to 0.0030) and MUA had better QALYs compared with ESP (0.0396; 95% CI -0.0008 to 0.0800). At a £20,000 per QALY willingness-to-pay threshold, MUA had the highest probability of being cost-effective (0.8632) then ESP (0.1366) and ACR (0.0002). The results were robust to sensitivity analyses.

Conclusion

While ESP was less costly, MUA was the most cost-effective option. ACR was not cost-effective.

Cite this article: Bone Jt Open 2021;2(8):685–695.

Treatment of Primary Shoulder Stiffness: Results of a Survey on Surgeon Practice Patterns in Italy

Objectives  Shoulder stiffness is a condition of restricted glenohumeral range of motion (ROM), which can arise spontaneously or as consequence of a known cause. Several treatment options are available and currently no consensus has been obtained on which treatment algorithm represents the best choice for the patient. The aim of this study was to investigate surgeon practice patterns in Italy regarding treatment of primary shoulder stiffness.

Methods  A literature review was performed to identify randomized controlled trials reporting results of shoulder stiffness treatment. The following controversial or critical points in the treatment of primary shoulder stiffness were identified: modalities of physical therapy; indication for oral corticosteroid; indication and frequency for injective corticosteroid; technique and site of injection; and indication, timing, and technique for surgery. A survey composed by 14 questions was created and administrated to the members of a national association specialized in orthopaedics and sports traumatology (SIGASCOT at the time of survey completion, recently renamed SIAGASCOT after the fusion of the societies SIGASCOT and SIA).

Results  A total of 204 completed questionnaires were collected. Physical therapy was recommended by 98% of the interviewed. The use of oral corticosteroids was considered by 51%, and injections of corticosteroids by 72%. The posterior injection approach was the one preferred and a number of three was considered the upper limit for repeated injections. Injective therapy with local anesthetics and hyaluronic acid was considered by more than 20% of the interviewed. Thirty percent of the interviewed did not treat shoulder stiffness surgically.

Conclusion  Several approaches to shoulder stiffness have been proposed and high-level evidence is available to analyze and discuss their results. Several controversial points emerged both from a literature review and from this national survey. Treatment of shoulder stiffness should be tailored to the patient's clinical situation and the stage of its pathology and should aim at pain reduction, ROM restoration, functional regain, and shortening of symptoms duration, with conservative therapy remaining the mainstay of treatment.

A prospective, comparative study of subacromial corticosteroid injection and subacromial corticosteroid injection plus suprascapular nerve block in patients with shoulder impingement syndrome

INTRODUCTION

Efforts are recently focused on the management of shoulder impingement syndrome (SIS) with a conservative and targeted approach because of its psychosocial impact, reduction in the quality of life, the cost to the economy and its negative effect on daily activities. Therefore, many studies have been designed to evaluate and compare the effectiveness of different treatments. The main purpose of this study was to identify the effect of combination of subacromial corticosteroid injection (SCI) and suprascapular nerve block (SSNB) on shoulder impingement syndrome (SIS).

MATERIALS AND METHODS

66 patients with SIS were randomly divided into two groups (33 patients per group): Group 1: SCI; Group 2: SCI plus SSNB. The estimation of the severity of pain by the visual analogue scale (VAS) and shoulder disability using quick DASH (Disabilities of the Arm, Shoulder and Hand) were assessed at baseline and 1, 3 months post-injection.

RESULTS

The mean age of patients was 55.55 ± 10.42 years in Group 1 and 57.24 ± 12.75 years in Group 2. In steroid group, pre- and post-treatment (at 1 and 3 months) VAS/quickDASH scores were 8.64 ± 0.99/78.03 ± 9.24, 2.09 ± 0.84/15.58 ± 7.23 and 3.06 ± 1.12/25.06 ± 8.74, respectively. In steroid plus SSNB group, pre- and post-treatment (at 1 and 3 months) VAS/quickDASH scores were 8.45 ± 0.90/75.15 ± 9.86, 1.24 ± 0.43/10.88 ± 2.14 and 1.51 ± 0.56/15.51 ± 5.04, respectively. Both treatment groups showed a significant relief of pain at 1 and 3 months post-injection (p < 0.05). However, the VAS and quickDASH scores at 1 and 3 months were significantly lower in Group 2 versus Group 1 (p < 0.05).

CONCLUSION

The combination of SCI and SSNB seems to produce the long-term effect in pain relief and functional improvement.

Clinical practice guidelines for the management of atraumatic shoulder conditions: protocol for a systematic review

INTRODUCTION

Shoulder conditions are a major cause of morbidity in the general population. Many clinical practice guidelines (CPGs) for shoulder conditions have been developed. Their purpose is to provide evidence-based recommendations to assist clinicians in providing optimal care to maximise patient outcomes. The aim of this systematic review is to identify, appraise, and compare the content and quality of CPGs for atraumatic shoulder conditions.

METHODS AND ANALYSIS

CPGs for atraumatic shoulder conditions will be included provided they make recommendations about diagnosis and/or management, are identified by their authors as a guideline and are consistent with the Appraisal of Guidelines for Research and Evaluation (AGREE) II definition of a guideline. A systematic search of electronic databases, online guideline repositories and the websites of relevant professional societies will be conducted to identify eligible CPGs. Search terms relating to shoulder conditions (eg, 'adhesive capsulitis', 'rotator cuff' and 'bursitis') will be combined with a validated search filter for CPGs. Pairs of independent reviewers will determine eligibility of CPGs identified by the search. Quality appraisal of included CPGs will be performed using the AGREE II instrument. Recommendations from each CPG and how they were determined will be extracted and compared across similar CPGs. Results from this systematic review will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement.

ETHICS AND DISSEMINATION

Ethical approval is not required for this systematic review. The results from this study will be published in a peer-reviewed journal and disseminated to professional societies that publish shoulder CPGs, clinical policy groups, clinicians, researchers and consumers.

PROSPERO REGISTRATION NUMBER

CRD42020182723.

Therapeutic efficacy of low-dose steroid combined with hyaluronidase in ultrasonography-guided intra-articular injections into the shoulder for adhesive capsulitis

PURPOSE

The purpose of this study was to compare the efficacy of low-dose steroid, high-dose steroid, and low-dose steroid combined with hyaluronidase with respect to intra-articular injection therapy for adhesive capsulitis (AC) of the shoulder.

METHODS

Thirty patients with primary AC in the initial stage were randomly assigned into three groups to receive ultrasound-guided intra-articular injections with 20 mg of triamcinolone acetonide (group A, n=10), 40 mg of triamcinolone acetonide (group B, n=10) and 20 mg of triamcinolone acetonide combined with hyaluronidase (group C, n=10). The outcome measures included a visual analogue scale (VAS), the Shoulder Disability Questionnaire (SDQ), abduction and external rotation range of motion, and intra-sheath fluid (ISF) before treatment and at 2, 4, 8, and 16 weeks after treatment.

RESULTS

Among the 30 patients, one participant in group B dropped out; therefore, a total of 29 patients completed this study and were successfully injected. After the injection, the VAS, SDQ, range of flexion and external rotation, and ISF improved in all groups compared with the preinjection status, regardless of treatment or time point. In the comparison between groups, the SDQ and ISF showed significantly greater improvements in groups B and C than in group A.

CONCLUSION

The therapeutic efficacy of combined low-dose corticosteroid and hyaluronidase is superior to that of low-dose corticosteroid and equivalent to that of high-dose corticosteroid in early AC.

Surgical treatments compared with early structured physiotherapy in secondary care for adults with primary frozen shoulder: the UK FROST three-arm RCT

BACKGROUND

Frozen shoulder causes pain and stiffness. It affects around 10% of people in their fifties and is slightly more common in women. Costly and invasive surgical interventions are used, without high-quality evidence that these are effective.

OBJECTIVES

To compare the clinical effectiveness and cost-effectiveness of three treatments in secondary care for adults with frozen shoulder; to qualitatively explore the acceptability of these treatments to patients and health-care professionals; and to update a systematic review to explore the trial findings in the context of existing evidence for the three treatments.

DESIGN

This was a pragmatic, parallel-group, multicentre, open-label, three-arm, randomised superiority trial with unequal allocation (2 : 2 : 1). An economic evaluation and a nested qualitative study were also carried out.

SETTING

The orthopaedic departments of 35 hospitals across the UK were recruited from April 2015, with final follow-up in December 2018.

PARTICIPANTS

Participants were adults (aged ≥ 18 years) with unilateral frozen shoulder, characterised by restriction of passive external rotation in the affected shoulder to < 50% of the opposite shoulder, and with plain radiographs excluding other pathology.

INTERVENTIONS

The inventions were early structured physiotherapy with a steroid injection, manipulation under anaesthesia with a steroid injection and arthroscopic capsular release followed by manipulation. Both of the surgical interventions were followed with post-procedural physiotherapy.

MAIN OUTCOME MEASURES

The primary outcome and end point was the Oxford Shoulder Score at 12 months post randomisation. A difference of 5 points between early structured physiotherapy and manipulation under anaesthesia or arthroscopic capsular release or of 4 points between manipulation under anaesthesia and arthroscopic capsular release was judged clinically important.

RESULTS

The mean age of the 503 participants was 54 years; 319 were female (63%) and 150 had diabetes (30%). The primary analyses comprised 473 participants (94%). At the primary end point of 12 months, participants randomised to arthroscopic capsular release had, on average, a statistically significantly higher (better) Oxford Shoulder Score than those randomised to manipulation under anaesthesia (2.01 points, 95% confidence interval 0.10 to 3.91 points; p = 0.04) or early structured physiotherapy (3.06 points, 95% confidence interval 0.71 to 5.41 points; p = 0.01). Manipulation under anaesthesia did not result in statistically significantly better Oxford Shoulder Score than early structured physiotherapy (1.05 points, 95% confidence interval -1.28 to 3.39 points; p = 0.38). No differences were deemed of clinical importance. Serious adverse events were rare but occurred in participants randomised to surgery (arthroscopic capsular release,n = 8; manipulation under anaesthesia,n = 2). There was, however, one serious adverse event in a participant who received non-trial physiotherapy. The base-case economic analysis showed that manipulation under anaesthesia was more expensive than early structured physiotherapy, with slightly better utilities. The incremental cost-effectiveness ratio for manipulation under anaesthesia was £6984 per additional quality-adjusted life-year, and this intervention was probably 86% cost-effective at the threshold of £20,000 per quality-adjusted life-year. Arthroscopic capsular release was more costly than early structured physiotherapy and manipulation under anaesthesia, with no statistically significant benefit in utilities. Participants in the qualitative study wanted early medical help and a quicker pathway to resolve their shoulder problem. Nine studies were identified from the updated systematic review, including UK FROST, of which only two could be pooled, and found that arthroscopic capsular release was more effective than physiotherapy in the long-term shoulder functioning of patients, but not to the clinically important magnitude used in UK FROST.

LIMITATIONS

Implementing physiotherapy to the trial standard in clinical practice might prove challenging but could avoid theatre use and post-procedural physiotherapy. There are potential confounding effects of waiting times in the trial.

CONCLUSIONS

None of the three interventions was clearly superior. Early structured physiotherapy with a steroid injection is an accessible and low-cost option. Manipulation under anaesthesia is the most cost-effective option. Arthroscopic capsular release carries higher risks and higher costs.

FUTURE WORK

Evaluation in a randomised controlled trial is recommended to address the increasing popularity of hydrodilatation despite the paucity of high-quality evidence.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN48804508.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 71. See the NIHR Journals Library website for further project information.

Ultrasound-Guided Versus Anatomic Landmark-Guided Steroid Injection of the Subacromial Bursa in the Management of Subacromial Impingement: A Systematic Review of Randomised Control Studies

This study is a systematic review of prospective randomised control studies comparing ultrasound-guided steroid injection of the subacromial space with anatomic landmark-guided injection in the treatment of subacromial impingement to determine if there is any difference in pain relief and functional outcome. Mesh terms and free-text words search of electronic databases, reference list of identified studies and grey literature was performed using the PICO format. All identified papers were sifted sequentially by title, abstract and review of full text articles. Four papers qualified and were included in the review and analysis. The total number of patients in the studies was 234 patients with 117 patients randomised to each of landmark-guided and ultrasound-guided injection groups. There was no statistically significant difference in VAS pain scores (P = 0.67), SDQ scores (P = 0.43), SPADI disability score (P = 0.17) and functional outcomes scores (P = 0.09) at 4 to 6 weeks when USS-guided subacromial steroid injection was compared with landmark-guided injection. SPADI pain scores (P = 0.02) demonstrates significant reduction in favour of landmark-guided injection. There was low to moderate risk of bias. In conclusion, ultrasound-guided subacromial steroid injection does not offer any statistically significant clinical improvement over landmark-guided injection in adults with subacromial impingement.

Ultrasound-guided versus blind subacromial corticosteroid and local anesthetic injection in the treatment of subacromial impingement syndrome: A randomized study of efficacy

Objectives

This study aims to compare the effects of ultrasound (US)-guided and blind subacromial corticosteroid and local anesthetic (LA) injection in the treatment of subacromial impingement syndrome (SIS) on shoulder pain, range of motion (ROM), and functionality.

Patients and methods

The prospective study was conducted between 01 February 2017 and 31 May 2017. A total of 29 patients with clinical findings and magnetic resonance imaging (MRI) consistent with SIS were randomized into two groups: 14 patients received US-guided subacromial corticosteroid and LA injection and 15 patients received a blind subacromial corticosteroid and LA injection. Patients were evaluated before and one month after treatment. One patient was lost to follow up. The primary outcome measure was a visual analog scale (VAS) for shoulder pain. Secondary outcomes were active shoulder ROM in flexion and abduction, the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and the modified Constant-Murley Score (CMS).

Results

Twenty eight patients (11 males, 17 females; mean age 39.5 in the US guided group and 42.5 in the blind group; range 20 to 64 years in both groups) completed the study. There was a significant improvement in VAS for shoulder pain, active ROM, DASH questionnaire score and modified CMS in both groups four weeks after treatment (p<0.05). There was no between-group difference in VAS, ROM or DASH questionnaire scores. Following treatment, the modified CMS in the US-guided injection group was higher than in the blind injection group (p=0.02). However, when the mean change in modified CMS in the US-guided injection group was compared to that of the blind injection group, the difference was insignificant (p=0.23).

Conclusion

Both US-guided and blind subacromial steroid injection improve shoulder pain, ROM, and functionality in SIS; one treatment option was not found to be superior to the other. Therefore, blind injection can be performed in clinical settings where US is not available. Equally, blind injection can also be performed in patients who have a definite diagnosis of SIS based on clinical and MRI findings.

General practice management of rotator cuff related shoulder pain: A reliance on ultrasound and injection guided care

OBJECTIVE

To describe general practitioner's (GP's) current management of rotator cuff related shoulder pain (RCRP) in Australia and identify if this is consistent with recommended care and best available evidence. The secondary aim was to determine if GP management of RCRP changed over time.

METHODS

Data about management of RCRP by Australian GPs was extracted from the Bettering the Evaluation of Care of Health program database over its final five years (April 2011-March 2016). Patient and GP characteristics and encounter management data were extracted. Results are reported using descriptive statistics with point estimates and 95% confidence intervals. A secondary analysis over a 16 year period (2000-2016) examined management data for RCRP in four year periods.

RESULTS

RCRP was the most common shoulder condition managed by GPs at 5.12 per 1,000 encounters; and at an estimated 732,000 times nationally in 2015-2016. Management rate was higher among male patients (5.5 per 1000 encounters c.f. 4.8 for female patients) and was highest in the 45-64 year old age group (8.6 per 1000). RCRP was most frequently managed with medications (54.7%), steroid injection (19.5%) followed by non-steroidal anti-inflammatory drugs (NSAIDs) (19.1%). Imaging was ordered for 43.4% (ultrasound 41.2% and x-ray 11.6%) of all RCRP presentations (new and returning). Over half (53.0%) of new RCRP presentations were referred for ultrasound imaging. In the 16 year period 2000-16 ultrasound imaging more than doubled from 19.1% to 41.9% of management occasions. In parallel, prescribed steroid injection increased from 9.8% to 19.7%.

CONCLUSION

The usual care provided by GPs for RCRP relies on the use of ultrasound and steroid injection. This is not consistent with recommended care and clinical guidelines that recommend these are delayed until after 6-12 weeks of NSAID medication, exercise and activity modification. There has been a significant increase in the rate of steroid injection and ultrasound imaging, which may be due in part to policy change.

Clinical indications for image-guided interventional procedures in the musculoskeletal system: a Delphi-based consensus paper from the European Society of Musculoskeletal Radiology (ESSR)-part I, shoulder

BACKGROUND

Image-guided interventional procedures around the shoulder are commonly performed in clinical practice, although evidence regarding their effectiveness is scarce. We report the results of a Delphi method review of evidence on literature published on image-guided interventional procedures around the shoulder with a list of clinical indications.

METHODS

Forty-five experts in image-guided musculoskeletal procedures from the ESSR participated in a consensus study using the Delphic method. Peer-reviewed papers regarding interventional procedures around the shoulder up to September 2018 were scored according to the Oxford Centre for Evidence-based Medicine levels of evidence. Statements on clinical indications were constructed. Consensus was considered as strong if more than 95% of experts agreed and as broad if more than 80% agreed.

RESULTS

A total of 20 statements were drafted, and 5 reached the highest level of evidence. There were 10 statements about tendon procedures, 6 about intra-articular procedures, and 4 about intrabursal injections. Strong consensus was obtained in 16 of them (80%), while 4 received broad consensus (20%).

CONCLUSIONS

Literature evidence on image-guided interventional procedures around the shoulder is limited. A strong consensus has been reached for 80% of statements. The ESSR recommends further research to potentially influence treatment options, patient outcomes, and social impact.

KEY POINTS

• Expert consensus produced a list of 20 evidence-based statements on clinical indications of image-guided interventional procedures around the shoulder. • The highest level of evidence was reached for five statements. • Strong consensus was obtained for 16 statements (80%), while 4 received broad consensus (20%).

A comparison of the effectiveness of lateral versus posterior approach to shoulder injection in patients with subacromial impingement syndrome: A pragmatic randomized controlled trial

OBJECTIVE

The aim of the study was to determine the effectiveness of the lateral approach to subacromial injection, compared with the posterior approach, for the treatment of subacromial impingement syndrome.

METHOD

A pragmatic randomized controlled trial was carried out in an outpatient community musculoskeletal service. The sample comprised 80 adults, aged 18 years or over, with subacromial impingement syndrome. The intervention group received a single subacromial injection, using a 21-gauge green needle, of 40 mg/ml triamcinolone acetonide (Kenalog) and 4 ml 1% lignocaine using a lateral approach. The control group received identical treatment, with the exception that the injection was given using a posterior approach. The outcome measures were pain measured using 0-10 numerical pain scale and shoulder pain and disability index (SPADI) scores at 8 and 12 weeks' follow-up.

RESULT

A moderate but statistically and clinically significant difference in improvement in daytime pain (mean change in score) occurred in favour of the lateral group (mean = 4.0) compared with the posterior group (mean = 2.0) between weeks 0 and 8 (1.4 points [95% confidence interval 0.3, 2.6; p = 0.018]). However, there were no statistically significant differences between the groups in night-time pain, shoulder function and SPADI scores. There was a statistically and clinically significant difference (p = 0.001) within the groups for all clinical outcomes between weeks 0 and 8, and between weeks 0 and 12.

CONCLUSION

There were no significant differences in the treatments; however, both forms of treatment were associated with a significant improvement in shoulder pain, function and disability.

2018 update of the EULAR recommendations for the management of hand osteoarthritis

Since publication of the European League Against Rheumatism (EULAR) recommendations for management of hand osteoarthritis (OA) in 2007 new evidence has emerged. The aim was to update these recommendations. EULAR standardised operating procedures were followed. A systematic literature review was performed, collecting the evidence regarding all non-pharmacological, pharmacological and surgical treatment options for hand OA published to date. Based on the evidence and expert opinion from an international task force of 19 physicians, healthcare professionals and patients from 10 European countries formulated overarching principles and recommendations. Level of evidence, grade of recommendation and level of agreement were allocated to each statement. Five overarching principles and 10 recommendations were agreed on. The overarching principles cover treatment goals, information provision, individualisation of treatment, shared decision-making and the need to consider multidisciplinary and multimodal (non-pharmacological, pharmacological, surgical) treatment approaches. Recommendations 1-3 cover different non-pharmacological treatment options (education, assistive devices, exercises and orthoses). Recommendations 4-8 describe the role of different pharmacological treatments, including topical treatments (preferred over systemic treatments, topical non-steroidal anti-inflammatory drugs (NSAIDs) being first-line choice), oral analgesics (particularly NSAIDs to be considered for symptom relief for a limited duration), chondroitin sulfate (for symptom relief), intra-articular glucocorticoids (generally not recommended, consider for painful interphalangeal OA) and conventional/biological disease-modifying antirheumatic drugs (discouraged). Considerations for surgery are described in recommendation 9. The last recommendation relates to follow-up. The presented EULAR recommendations provide up-to-date guidance on the management of hand OA, based on expert opinion and research evidence.

Correction between the Morphology of Acromion and Acromial Angle in Chinese Population: A Study on 292 Scapulas

Introduction. The acromion is a small section of the scapula which extends anteriorly from the spine of the scapula and the acromial angle (AA) is a prominent bony point at the junction of the lateral border of the acromion and the spine of the shoulder blade. As is well known, the morphology of the acromion and the acromial angle are important as their anatomical variation may contribute to shoulder pathologies. However, few people have studied the morphology and the association between the acromion and the acromial angle. The study explores the acromion and the acromial angle in the anatomical morphology and the association, providing an anatomical basis for clinical diagnosis and treatment. Material and Methods. A total of 292 dry, intact scapulae (152 right, 140 left) were used in the study. Three types of the acromion were already measured, type I(flat shape), type II (curved shape), and type III (hooked shape), respectively. Three types of the acromial angles were also measured in this study, C shape, L shape, and Double Angle shape. Results. The research result shows that C shape and L shape were the most common, while Double Angle shape was the least common. C shape was often related to type I (flat shape) and L shape was often related to type II (curved shape). Conclusions. The presented data provides precise and well-sorted information about the acromion and the acromial angle variation in Chinese population, contributing to diagnosis and treating in shoulder pathology.

Comparative functional outcomes of patients with adhesive capsulitis receiving intra-articular versus sub-acromial steroid injections: case-control study

PURPOSE

This is a prospective case-control study comparing short- and medium-term outcomes between sub-acromial and gleno-humeral corticosteroid injections in adhesive capsulitis.

METHODS

The study population consisted of 105 patients (33 males, 72 females; mean age, 56.1 years). They were divided into three groups: (1) patients receiving 40 mg of methylprednisolone acetate as intra-articular injection (n = 35) followed by physical therapy; (2) patients receiving 40 mg of methylprednisolone acetate as sub-acromial injection (n = 35) followed by physical therapy; (3) patients receiving only physical therapy (heat, passive stretching exercises and wall climbing) and no injections (n = 35). Functional outcome scores (Constant shoulder score and Shoulder Pain and Disability Index), visual analogue scale for pain and range of motion of shoulder joint were noted at 3, 6 and 12 weeks and 6 months.

RESULTS

There was a statistically significant improvement in VAS scores in group 1 and 2 at 3, 6, 12 weeks and 6 months compared to that before the injections. There was no statistically significant improvement in the group 3 at 3 and 6 weeks, but improvement was noticed at 12 weeks and 6 months. There was no statistically significant difference in VAS, CS score, SPADI and ROM between groups 1 and 2 at 3, 6, 12 weeks and 6 months. These scores were significantly better in group 1 and 2 compared to group 3 at 3, 6, 12, weeks and 6 months.

CONCLUSIONS

Corticosteroid injections into the sub-acromial space and into the gleno-humeral joint produce similar results in terms of pain relief and improvement in function in patients with adhesive capsulitis.

Existing Evidence on Ultrasound-Guided Injections in Sports Medicine

Office-based ultrasonography has become increasingly available in many settings, and its use to guide joint and soft tissue injections has increased. Numerous studies have been conducted to evaluate the use of ultrasound-guided injections over traditional landmark-guided injections, with a rapid growth in the literature over the past few years. A comprehensive review of the literature was conducted to demonstrate increased accuracy of ultrasound-guided injections regardless of anatomic location. In the upper extremity, ultrasound-guided injections have been shown to provide superior benefit to landmark-guided injections at the glenohumeral joint, the subacromial space, the biceps tendon sheath, and the joints of the hand and wrist. Ultrasound-guided injections of the acromioclavicular and the elbow joints have not been shown to be more efficacious. In the lower extremity, ultrasound-guided injections at the knee, ankle, and foot have superior efficacy to landmark-guided injections. Conclusive evidence is not available regarding improved efficacy of ultrasound-guided injections of the hip, although landmark-guided injection is performed less commonly at the hip joint. Ultrasound-guided injections are overall more accurate than landmark-guided injections. While current studies indicate that ultrasound guidance improves efficacy and cost-effectiveness of many injections, these studies are limited and more research is needed.

Are corticosteroid injections more beneficial than anaesthetic injections alone in the management of rotator cuff-related shoulder pain? A systematic review

Objective

To compare the effectiveness of corticosteroid injections to local anaesthetic injections in the management of rotator cuff-related shoulder pain (RCRSP).

Design

Systematic review with best evidence synthesis.

Data sources

The Cochrane, PubMed, CINAHL Plus, PEDro and EMBASE electronic databases were searched (inception until 8 June 2017). Reference lists of included articles were also hand searched.

Eligibility criteria

Two reviewers independently evaluated eligibility. Randomised controlled trials (RCTs) were included if they compared subacromial injections of corticosteroid with anaesthetic injections. Two reviewers independently extracted data regarding short-term, midterm and long-term outcomes for pain, self-reported function, range of motion and patient-perceived improvement.

Results

Thirteen RCTs (n=1013) were included. Four trials (n=475) were judged as being at low risk of bias. Three studies of low risk of bias favoured the use of corticosteroid over anaesthetic-only injections in the short term (up to 8 weeks). There was strong evidence of no significant difference between injection types in midterm outcomes (12–26 weeks). There was limited evidence of no significant difference between injection types in long-term outcomes.

Conclusion

Corticosteroid injections may have a short-term benefit (up to 8 weeks) over local anaesthetic injections alone in the management of RCRSP. Beyond 8 weeks, there was no evidence to suggest a benefit of corticosteroid over local anaesthetic injections.

Trial registration number

PROSPERO CRD42016033161.

United Kingdom Frozen Shoulder Trial (UK FROST), multi-centre, randomised, 12 month, parallel group, superiority study to compare the clinical and cost-effectiveness of Early Structured Physiotherapy versus manipulation under anaesthesia versus arthroscopic capsular release for patients referred to secondary care with a primary frozen shoulder: study protocol for a randomised controlled trial

BACKGROUND

Frozen shoulder (also known as adhesive capsulitis) occurs when the capsule, or the soft tissue envelope around the ball and socket shoulder joint, becomes scarred and contracted, making the shoulder tight, painful and stiff. It affects around 1 in 12 men and 1 in 10 women of working age. Although this condition can settle with time (typically taking 1 to 3 years), for some people it causes severe symptoms and needs referral to hospital. Our aim is to evaluate the clinical and cost-effectiveness of two invasive and costly surgical interventions that are commonly used in secondary care in the National Health Service (NHS) compared with a non-surgical comparator of Early Structured Physiotherapy.

METHODS

We will conduct a randomised controlled trial (RCT) of 500 adult patients with a clinical diagnosis of frozen shoulder, and who have radiographs that exclude other pathology. Early Structured Physiotherapy with an intra-articular steroid injection will be compared with manipulation under anaesthesia with a steroid injection or arthroscopic (keyhole) capsular release followed by manipulation. Both surgical interventions will be followed with a programme of post-procedural physiotherapy. These treatments will be undertaken in NHS hospitals across the United Kingdom. The primary outcome and endpoint will be the Oxford Shoulder Score (a patient self-reported assessment of shoulder function) at 12 months. This will also be measured at baseline, 3 and 6 months after randomisation; and on the day that treatment starts and 6 months later. Secondary outcomes include the Disabilities of Arm Shoulder and Hand (QuickDASH) score, the EQ-5D-5 L score, pain, extent of recovery and complications. We will explore the acceptability of the different treatments to patients and health care professionals using qualitative methods.

DISCUSSION

The three treatments being compared are the most frequently used in secondary care in the NHS, but there is uncertainty about which one works best and at what cost. UK FROST is a rigorously designed and adequately powered study to inform clinical decisions for the treatment of this common condition in adults.

TRIAL REGISTRATION

International Standard Randomised Controlled Trial Register, ID: ISRCTN48804508 . Registered on 25 July 2014.

The incidence of flare reaction and short-term outcome following steroid injection in the shoulder

BACKGROUND

To determine the short-term effects following corticosteroid injection into the shoulder.

METHODS

Type-specific shoulder injection was administered, followed by physiotherapy 7 days to 10 days later. One hundred and sixteen adult patients were prospectively followed-up. The primary outcome was a visual analogue score (VAS) for pain. Scores were recorded immediately before injection, 30 minutes after, daily until day 7 and then at 6 weeks. Post injection pain was defined as an increase of 2 or more points in the VAS score after the injection. The secondary outcome was determined at 6 months as successful discharge or progression onto surgery.

RESULTS

The VAS showed a significant reduction from the pre-injection score for all patients at day 1 and was maintained until week 6. Forty-one (35.3%) patients experienced post-injection pain. The mean duration of symptoms was 3.9 days. At 6 months, 81 (69.8%) patients were discharged successfully and, at a mean of 23.2 months, did not require re-referral; 29 (25%) had surgery; and six (5.2%) were referred for a spinal opinion.

CONCLUSIONS

One in three patients developed delayed post-injection pain. Flare phenomenon had no determinate effect on outcome. Patients' pain response by 6 weeks is predictive of final outcome at 6 months and may help clinicians plan further treatment without delay.

Ultrasound-Guided Versus Blind Subacromial Corticosteroid Injections for Subacromial Impingement Syndrome: A Randomized, Double-Blind Clinical Trial

BACKGROUND

Subacromial corticosteroid injections are frequently performed for impingement syndrome of the shoulder. To improve the accuracy of injections, ultrasound can be used.

PURPOSE

To assess the clinical outcome of ultrasound-guided subacromial injections compared with blind subacromial injections for subacromial impingement syndrome.

STUDY DESIGN

Randomized controlled clinical trial; Level of evidence, 1.

METHODS

A total of 56 shoulders with subacromial impingement syndrome were randomized into 2 groups: 28 shoulders received a subacromial corticosteroid injection with ultrasound guidance (ultrasound group), and 28 shoulders received a subacromial corticosteroid injection without ultrasound guidance (blind group). The visual analog scale (VAS) for pain with overhead activities and the American Shoulder and Elbow Surgeons (ASES) score were obtained before the injection and at 6 weeks after the injection.

RESULTS

The VAS score for pain with overhead activities decreased from 59 ± 5 mm (mean ± SEM) before the injection to 33 ± 6 mm at 6 weeks after the injection in the ultrasound group (P < .001) and from 63 ± 4 mm to 39 ± 6 mm, respectively, in the blind group (P < .001). The decrease in the VAS score was not significantly different between the groups (P > .999). The ASES score increased from 57 ± 2 before the injection to 68 ± 3 at 6 weeks after the injection in the ultrasound group (P < .01) and from 54 ± 3 before the injection to 65 ± 4 after the injection in the blind group (P < .01), with no significant difference between the groups (P = .7). Four shoulders (14%) in the ultrasound group and 6 shoulders (21%) in the blind group eventually needed surgery (P = .7).

CONCLUSION

No significant differences were found in the clinical outcome when comparing ultrasound-guided subacromial injections to blind subacromial injections for subacromial impingement syndrome.

CLINICAL TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry: ACTRN12615000562572.

Effectiveness of Blind & Ultrasound Guided Corticosteroid Injection in Impingement Syndrome

Local steroid injections are common for treatment of impingement syndrome. Corticosteroid injections methods are basically in two formats, blind or with image guidance. The aim of this study is to compare the effect of ultrasound-guided in comparison with blind corticosteroid injections in patients with impingement syndrome. This study is a randomized clinical trial study undertaken in patients with diagnosis of impingement syndrome done in Isfahan University of Medical Science clinics from February 2014 to February 2015. The number of all patients registered in the study is 48; and then 40 patients were allocated to either control group randomly which received blind steroid injection or case group that underwent ultrasound-guided steroid injection. The clinical symptoms were assessed using Shoulder Pain and Disability Index (SPADI) questionnaire, Visual Analogue Scale (VAS) and shoulder range of motion (ROM) using goniometer at baseline and six weeks after the injection. Data analysis revealed a significant difference in the mean of the VAS, SPADI and shoulder ROM in both groups 6 weeks after intervention (P < 0.05). Patients with ultrasound guided corticosteroid injection had statistically significant improvements in function and shoulder ROM (abduction, flexion) compared to blind injection group after 6 weeks (P<0.05). There was not significant differences in pain (VAS) and internal and external rotation between these two groups (p>0.05). Our findings suggest that US image guided can improve the shoulder function of patients with impingement syndrome, and thus can be considered in comprehensive care programs of these patients for fast speed of rehabilitation.

Ultrasound-guided interventional procedures for chronic pain management

Ultrasonography has multiple advantages over traditional radiologic imaging modalities when used for interventional procedures. It allows improved visualization of the anatomy while avoiding ionizing radiation and risks associated with contrast use. It has proved superiority at accuracy of delivery and procedural effectiveness over blind procedures when used in association with interventional pain procedures. Although limited in its ability to see through bony structures, ultrasound has utility in visualizing soft tissues and vascular structures in anatomic regions of interest resulting in increased use for posterior neuraxial, periaxial, peripheral nerve and joint-related structures. Current evidence for use in these settings is presented here. In some cases, optimal utility may be improved by combining ultrasonography with other imaging modalities.

Methicillin-resistant Staphylococcus aureus infection of the subacromial bursa: an unusual complication following subacromial corticosteroid injection (a report of two cases)

Subacromial corticosteroid injections are frequently used for both diagnostic and therapeutic purposes in shoulder pain. Subacromial septic bursitis is a recognized but rare complication. There have been no reports of methicillin-resistant Staphylococcus aureus infections of the subacromial bursa after subacromial injections in the literature. We describe case reports of two patients who presented with subacromial methicillin-resistant Staphylococcus aureus septic bursitis following subacromial corticosteroid injections in the community and highlight the diagnostic and management challenges of this condition.

Shoulder disorders and occupation

Shoulder pain is very common, and it causes substantial morbidity. Standardised classification systems based upon presumed patho-anatomical origins have proved poorly reproducible and hampered epidemiological research. Despite this, there is evidence that exposure to combinations of physical workplace strains such as overhead working, heavy lifting and forceful work as well as working in an awkward posture increases the risk of shoulder disorders. Psychosocial risk factors are also associated. There is currently little evidence to suggest that either primary prevention or treatment strategies in the workplace are very effective, and more research is required, particularly around the cost-effectiveness of different strategies.

Effectiveness of hyaluronic acid administration in treating adhesive capsulitis of the shoulder: a systematic review of randomized controlled trials

Introduction. Adhesive capsulitis (AC) of the shoulder presents with an insidious onset of pain and progressive limitation of shoulder movement. Objectives. To investigate whether intra-articular hyaluronic acid (HA) administration alone is superior to conventional therapies and whether the addition of intra-articular HA administration to conventional therapies improves clinical outcomes in patients with AC. Methods. The PubMed, EMBASE, CINAHL, and Cochrane Library electronic databases were searched without language restrictions in July 2014 with a priori defined inclusion and exclusion criteria. Results. Four randomized controlled trials (273 participants, 278 shoulders) were included in this review. Two trials compared intra-articular HA administration with conventional therapies and 2 trials evaluated intra-articular HA administration as an addition to conventional therapies. Pain and shoulder function/disability outcomes in the HA injection group were not superior to those achieved in the conventional therapy groups. No significant differences in pain or shoulder function/disability outcomes were noted between the groups with and without adjunctive HA administration. Conclusions. Intra-articular HA administration alone is not superior to conventional AC treatments, and the addition of intra-articular HA administration to conventional therapies does not provide significant added benefits. HA administration in AC patients who are receiving conventional therapies should be evaluated to avoid unnecessary medical expenditure.

An experienced physiotherapist prescribing and administering corticosteroid and local anaesthetic injections to the shoulder in an Australian orthopaedic service, a non-inferiority randomised controlled trial and economic analysis: study protocol for a randomised controlled trial

BACKGROUND

The early management of orthopaedic outpatients by physiotherapists may be useful in reducing public hospital waiting lists. Physiotherapists in Australia are prevented by legislation and funding models from investigating, prescribing, injecting and referring autonomously. This gap in service is particularly noticeable in the management of shoulder pain in early-access physiotherapy services, as patients needing corticosteroid injection face delays or transfer to other services for this procedure. This trial will investigate the clinical (decision making and outcomes) and economic feasibility of a physiotherapist prescribing and delivering corticosteroid and local anaesthetic injections for shoulder pain in an Australian public hospital setting.

METHODS/DESIGN

A double-blinded (patient and assessor) non-inferiority randomised controlled trial will compare an orthopaedic surgeon and a physiotherapist prescribing and delivering corticosteroid injections to the shoulder. Agreement in decision making between the two clinicians will be investigated, and economic information will be obtained for estimating disease burden and an economic evaluation. The surgeon and the physiotherapist will independently assess patients, and 64 eligible participants will be randomised to receive subacromial injection of corticosteroid and local anaesthetic from either the surgeon or the physiotherapist. Post-injection, all participants will receive physiotherapy. The primary outcome measure will be the Shoulder Pain and Disability Index measured at baseline, and at 6 and 12 weeks post-injection. Analysis will be conducted on an intention-to-treat basis and compared to a per-protocol analysis. A cost-utility analysis will be undertaken from the perspective of the health funder.

DISCUSSION

Findings will assist policy makers and services in improving access for orthopaedic patients.

TRIAL REGISTRATION

Australia and New Zealand Clinical Trials Registry: 12612000532808 First registered: 21 May 2012. First participant randomized: 16 January 2013.

Role of rehabilitation medicine and physical agents in the treatment of cancer-associated pain

PURPOSE

To provide an overview of rehabilitation medicine- and physical modality-based approaches to cancer pain management, and to highlight the fact that these approaches are generally used in conjunction and that a majority are focused on minimizing pain during periods of mobility and the performance of activities of daily living.

METHODS

We performed a nonsystematic literature review and provide a description of the current standard of care.

RESULTS

Rehabilitative and physical modalities used to manage pain can be grouped into four categories: those that modulate nociception, stabilize or unload painful structures, influence physiological processes that indirectly influence nociception, or alleviate pain arising from the overloading of muscles and connective tissues that often occurs after surgery or with sarcopenia in late-stage cancer. Most modalities have been pragmatically refined over the years, and many have an evidence base, although few have been explicitly validated in the oncologic setting. With few exceptions, they are patient controlled and free of adverse effects.

CONCLUSION

Physical modalities and rehabilitation medicine offer a range of pain management approaches that may serve as beneficial adjuncts to the conventional systemic and interventional analgesic strategies used to control cancer-related pain. These approaches may be particularly beneficial to patients with movement-associated pain and those who are ambivalent regarding pharmacoanalgesia.

Evaluation and treatment of shoulder pain

Shoulder pain is a common symptom in the adult population. The most common cause of shoulder pain is SIS, reflecting a problem with the rotator cuff or subacromial bursa. Determining the cause of a patient’s pain is usually a clinical diagnosis based on careful history taking and physical examination. Limited use of imaging studies will be needed in the setting of trauma, possible glenohumeral arthritis, or when a complete tendon tear is suspected. Therapy is based on pain control and therapeutic exercises in almost all cases. Despite the prevalence of shoulder pain, there is no consensus on the best way to achieve pain control or on the type of exercise most likely to achieve speedy recovery.

Ultrasound-guided interventional procedures around the shoulder

The aim of this review is to illustrate the spectrum of ultrasound-guided procedures around the shoulder. The shoulder is affected by a wide range of both, traumatic and degenerative diseases. Ultrasound guidance is a low-cost and safe tool to perform minimally invasive interventional procedures around the shoulder. The clinical outcome is shown by the use of clinical scores: visual analogue scale (VAS), Constant's score and Shoulder Pain Disability Index (SPADI). Rotator cuff calcification is a common painful condition that occurs in up to 7.5 % of otherwise healthy adults. Ultrasound-guided procedures include single-needle and double-needle approach with different needles. These techniques are described and the results are critically compared. Ultrasound-guided viscosupplementation is a new therapeutic approach for treatment of several shoulder pain disorders: osteoarthritis, rotator cuff tear and tendinosis. In adhesive capsulitis, different therapeutic ultrasound-guided techniques such as corticosteroid injection, capsular distension (sodium chlorate solution; sodium chlorate and corticosteroids; air) and viscosupplementation are evaluated. Acromion-clavear injection of steroid and lidocaine solution under ultrasound guidance is easy to perform and is indicated in conservative treatment of painful osteoarthrosis. The treatment of rotator cuff tendinosis and partial tears with ultrasound-guided injection of concentrated autologous platelets is also described.