Methylprednisolone versus triamcinolone in painful shoulder using ultrasound-guided injection

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.

Clinical Guidelines in the Management of Frozen Shoulder: An Update!

Among all the prevalent painful conditions of the shoulder, frozen shoulder remains one of the most debated and ill-understood conditions. It is a condition often associated with diabetes and thyroid dysfunction, and which should always be investigated in patients with a primary stiff shoulder. Though the duration of 'traditional clinicopathological staging' of frozen shoulder is not constant and varies with the intervention(s), the classification certainly helps the clinician in planning the treatment of frozen shoulder at various stages. Most patients respond very well to combination of conservative treatment resulting in gradual resolution of symptoms in 12-18 months. However, the most effective treatment in isolation is uncertain. Currently, resistant cases that do not respond to conservative treatment for 6-9 months could be offered surgical treatment as either arthroscopic capsular release or manipulation under anaesthesia. Though both invasive options are not clinically superior to another, but manipulation could result in unwarranted complications like fractures of humerus or rotator cuff tear.

Intra-substance steroid injection for full-thickness supraspinatus tendon rupture

Background

The use of steroid injection for treatment of a full-thickness rotator cuff tear is still controversial. This study aimed to evaluate the effectiveness and safety of this treatment method.

Methods

Twelve patients in Group 1 received an intra-substance injection into rupture area of supraspinatus tendon with Diprospan 1 cc (betamethasone disodium phosphate 2 mg and betamethasone dipropionate 5 mg) and 1% xylocaine 1 cc. Twelve patients in Group 2 received an injection with normal saline 1 cc and 1% xylocaine 1 cc. The rupture size was measured by sonography before the injection, 3 months after the injection, and 6 months after the injection. Shoulder Pain and Disability Index (SPADI) score and Pain Visual Analogue Scale (VAS) score were measured and compared between the two groups before the injection, 1 week after the injection, 3 months after the injection, and 6 months after the injection.

Results

Pain and function improved more in Group 1 than in Group 2. The therapeutic effect lasted for at least 6 months in both groups. The size of the supraspinatus tendon rupture was not increased after injection in either group.

Conclusions

Intra-substance injection into rupture area of supraspinatus tendon with steroid and xylocaine is effective to reduce pain and improve function in patients with full-thickness supraspinatus tendon rupture without increasing the size of the rupture.

Trial registration

Current Controlled Trials ChiCTR1900026376, data of registration: 2019/10/05 retrospectively registered.

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%).

Efficacy of fluoroscopy-guided triple shoulder injection for older patients with nonspecific shoulder pain

PURPOSE

Nonspecific shoulder pain is a common complaint in older adults that impairs physical function by restricting the range of joint movement, and causing severe pain. The study evaluated the effects of fluoroscopy-guided triple shoulder injection [i.e., injection into glenohumeral (GH) joint, subacromial (SA) space, and acromioclavicular (AC) joint] on pain, function, and range of motion in older patients with nonspecific shoulder pain.

METHODS

A total of 43 patients who were aged 65 years and older and diagnosed with nonspecific shoulder pain were included in this prospective, non-randomized clinical trial; 65.1% of the patients were female and mean age was 70.2 ± 5.0. Under fluoroscopic guidance, a mixture of methylprednisolone and bupivacaine was injected into the GH joint, SA space and AC joint. Patients were evaluated as per the Numeric Rating Scale for Pain (NRS-Pain), the Shoulder Pain and Disability Index (SPADI), and the active range of motion (AROM) at baseline, and again at 3 and 12 weeks after the injection.

RESULTS

A statistically significant improvement was detected in NRS-Pain, SPADI, and AROM at 3 and 12 weeks after injection compared with baseline. The change in SPADI score from baseline was higher than the minimal detectable change in 67.4% of patients at 12 weeks. The SPADI score at baseline was positively correlated with the post-injection SPADI score at 3 and 12 weeks.

CONCLUSIONS

In older patients with nonspecific shoulder pain, fluoroscopy-guided triple shoulder injection provides significant improvements in pain and physical function with low complication rates during the 12-week follow-up.

Imaging-guided subacromial therapeutic injections: prospective study comparing abnormalities on conventional radiography with patient outcomes

OBJECTIVE

The purpose of this study was to compare abnormalities detected on conventional shoulder radiography with improvement in pain and shoulder function after subacromial injections.

SUBJECTS AND METHODS

We conducted a prospective outcomes study including 98 consecutive patients after fluoroscopy-guided subacromial injections who returned outcome questionnaires and who underwent routine shoulder radiography. Numeric pain rating scale (NRS) data were collected before and, along with patient global impression of change (PGIC) data, at 1 week and 1 month after injection. Outcome differences were assessed using the Student t test and Mann-Whitney U test. Logistic regression analysis was done, including radiographic variables compared with the outcome improvement. The odds ratios with 95% CIs were identified for the significant predictors.

RESULTS

A significant difference in overall improvement was found depending on the posterior acromial slope. Patients with a slope of more than 36° had significantly lower NRS and PGIC scores at 1 week and 1 month (p < 0.025) compared with those with a slope of 36° or less, with 86.4% of patients with a slope of more than 36° reporting significant improvement at 1 month. This was the only variable linked with improvement in the logistic regression analysis, with an odds ratio of 2.16 (95% CI, 1.11-4.22). Patients with calcific tendinitis had significantly lower NRS scores at both 1 week and 1 month (p = 0.03 and 0.05, respectively) and PGIC scores at 1 week (p = 0.05).

CONCLUSION

A posterior acromial slope of more than 36° and the presence of calcific tendinitis on conventional shoulder radiography are associated with better outcomes. Patients with a slope of more than 36° showed the best improvement.

Intra-articular corticosteroid injection in diabetic patients with adhesive capsulitis: a randomized controlled trial

PURPOSE

An intra-articular corticosteroid injection is considered an effective treatment for idiopathic adhesive capsulitis of the shoulder. This study examined the efficacy of corticosteroid injections for the treatment for adhesive capsulitis in patients with diabetes mellitus.

METHODS

Forty-five diabetic patients were randomized into a corticosteroid injection group or non-injection control group and received the same instruction for a home stretching exercise. The corticosteroid group patients were administered intra-articular corticosteroid injection composed of 40 mg triamcinolone acetonide. Pain by a visual analogue scale, shoulder range of motion, and functional state by the American Shoulder and Elbow score were assessed at the baseline, 4-, 12-, and 24-week follow-up.

RESULTS

Diabetic patients treated with corticosteroid injections showed significant improvement in the pain score at 4 weeks and in the functional score at 12 weeks (P = 0.020 and P = 0.042, respectively). The range of motion in forward elevation and internal rotation was significantly higher in the corticosteroid group than in the non-corticosteroid group at the 12-week follow-up (P = 0.030 and 0.045, respectively), but there were no significant differences at the final follow-up between the corticosteroid and non-corticosteroid groups.

CONCLUSIONS

A corticosteroid injection in diabetic patients decreases the pain perception and accelerates the functional recovery in the early post-injection period. An intra-articular corticosteroid injection is considered a viable option for the treatment for adhesive capsulitis with diabetes.

LEVEL OF EVIDENCE

Randomized clinical trial, therapeutic study, Level II.

Effectiveness of ultrasound-guided injections combined with shoulder exercises in the treatment of subacromial adhesive bursitis

The aim of this study was to evaluate whether the association of exercises for the shoulder with ultrasound-guided injection into the bursa significantly improves the treatment outcome in adhesive bursitis. Two groups of 35 patients, one treated with ultrasound-guided injection (UGI) and the other one with ultrasound-guided injection and home exercise program (UGI-exercise) for 1 month, were assessed for pain and shoulder function before treatment, 1 and 3 months post-treatment. Fourteen patients in UGI group and 23 patients in the UGI-exercises group were completely free of pain after 1 month (p = 0.031). At 3 months' follow-up, patients in the UGI-exercise group showed a significant improvement with respect to the other group (p = 0.005). No differences were found in function assessment. The UGI combined with shoulder exercises in the treatment of subacromial adhesive bursitis is effective to ensure a more frequent complete pain relief in the medium term.

The effectiveness of corticosteroid injections compared with physiotherapeutic interventions for adhesive capsulitis: a systematic review

OBJECTIVES

To determine the effectiveness of corticosteroid injections compared with physiotherapeutic interventions for the treatment of adhesive capsulitis/frozen shoulder.

DATA SOURCES

The electronic databases MEDLINE, EMBASE, CINAHL and AMED were searched up to Week 23 2009. Additional database searching included the Cochrane Central Register of Controlled Clinical Trials, the Physiotherapy Evidence Database (PEDro), the National Research Register and the National Recognition Information Centre, also up to Week 23 2009.

REVIEW METHODS

All English-language studies were eligible for inclusion if they showed evidence of random allocation of subjects to either a corticosteroid injection group or a physiotherapeutic intervention group. Studies were considered for inclusion if participants had a stated diagnosis of adhesive capsulitis/frozen shoulder or restriction of passive or active movement in two or more planes. The primary outcomes of interest were pain, external rotation and shoulder disability/function. Quality assessment was assessed using the PEDro scale. Standardised mean differences and effect estimates were calculated for the outcomes of pain, external rotation and shoulder disability at various follow-up periods.

RESULTS

Six studies were deemed eligible for inclusion in the final review. All had evidence of random allocation to either an injection group or a physiotherapeutic intervention group. There were some differences between the studies with regard to both the corticosteroid injections and physiotherapeutic interventions. Standardised mean differences and effect estimates were calculated for three of the included studies at various follow-up periods. There was a medium effect for corticosteroid injections compared with physiotherapeutic interventions for the outcomes of pain, passive external rotation and shoulder disability at 6 weeks. There was only a small effect in favour of corticosteroid injections for pain, passive external rotation and shoulder disability at 12 to 16 weeks and 26 weeks, and pain and shoulder disability at 52 weeks.

CONCLUSION

The results of this review suggest that corticosteroid injections have greater effect in the short term compared with physiotherapeutic interventions. This decreased over time, with only a small effect in favour of injections in the longer term. The results of this review must be interpreted with some caution due to the limited number of studies and differences in the interventions between the studies.