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

A high level of scientific evidence is available to guide treatment of primary shoulder stiffness: The SIAGASCOT consensus

PURPOSE

Shoulder stiffness (SS) is a condition characterised by active and passive restricted glenohumeral range of motion, which can occur spontaneously in an idiopathic manner or be associated with a known underlying aetiology. Several treatment options are available and currently no consensus has been obtained on which treatment algorithm represents the best choice for the patient. Herein we present the results of a national consensus on the treatment of primary SS.

METHODS

The project followed the modified Delphi consensus process, involving a steering, a rating and a peer-review group. Sixteen questions were generated and subsequently answered by the steering group after a thorough literature search. A rating group composed by professionals specialised in the diagnosis and treatment of shoulder pathologies rated the question-answer sets according to the scientific evidence and their clinical experience.

RESULTS

Recommendations were rated with an average of 8.4 points out of maximum 9 points. None of the 16 answers received a rating of less than 8 and all the answers were considered as appropriate. The majority of responses were assessed as Grade A, signifying a substantial availability of scientific evidence to guide treatment and support recommendations encompassing diagnostics, physiotherapy, electrophysical agents, oral and injective medical therapies, as well as surgical interventions for primary SS.

CONCLUSIONS

A consensus regarding the conservative and surgical treatment of primary SS could be achieved at a national level. This consensus sets basis for evidence-based clinical practice in the management of primary SS and can serve as a model for similar initiatives and adaptable guidelines in other European countries and potentially on a global scale.

LEVEL OF EVIDENCE

Level I.

Outcomes of ketorolac versus depomedrol infiltrations for subacromial impingement syndrome: a randomized controlled trial

PURPOSE

Local subacromial infiltration with steroids is a common method of treatment of subacromial impingement syndrome. However, the use of steroids has concerns like tendon rupture, articular cartilage changes and infections. Local NSAIDs infiltration has recently been tried in literature. This study compares the effect of subacromial injections of ketorolac with steroids.

METHODS

A randomized controlled study was planned with 35 patients in each group. Patients in group-1 were infiltrated with subacromial ketorolac (60 mg with 2% lignocaine) and in group-2 with a steroid (methylprednisolone-40 mg with 2% lignocaine). A similar rehabilitation protocol was followed, and clinical outcomes were analyzed using visual analog scale (VAS) for pain and shoulder pain and disability score (SPADI) and range of motion at one-month and three-months follow-up.

RESULTS

Total data of 67 patients were analyzed, as three patients were lost to follow-up. In group 1, mean VAS improved from 7.9 [Formula: see text] 0.95 to 3.19 [Formula: see text] 0.81 (p < 0.001) and SPADI improved from 61.41 [Formula: see text] 11.86 to 28.91 [Formula: see text] 9.06 (p < 0.001) at three months, respectively. In group 2, mean VAS improved from 8.05 [Formula: see text] 0.94 to 2.9 [Formula: see text] 0.64 (p < 0.001) and SPADI improved from 63.45 [Formula: see text] 9.64 to 25.32 [Formula: see text] 6.87 (p < 0.001) at three months, respectively. However, there were no differences in functional outcomes between the groups (p = 0.21 for VAS, p = 0.16 for SPADI).

CONCLUSION

Subacromial ketorolac infiltration has an equivalent outcome as that of steroid infiltration. Ketorolac could be considered as a reasonable alternative to steroids in cases where it is contraindicated.

Proximal Approach of Ultrasound-guided Suprascapular Nerve Block: Comparison with Subacromial Steroid Injection

BACKGROUND

This study was undertaken to evaluate early clinical outcomes of ultrasound-guided suprascapular nerve block (SSNB) using a proximal approach, as compared with subacromial steroid injection (SA).

METHODS

This retrospective study included a consecutive series of 40 patients of SSNB and 20 patients receiving SA, from August 2017 to August 2018. The visual analogue scale (VAS), American Shoulder Elbow Surgeon's score (ASES), University of California, Los Angeles score (UCLA), the 36 health survey questionnaire mental component summary (SF36-MCS), physical component summary (PCS), and range of motion (forward elevation, external rotation, and internal rotation) were assessed for clinical evaluations.

RESULTS

Compared with the baseline, VAS, and ranges of motion in the SSNB group significantly improved at the 4-week follow-up (VAS scores improved from 6.7 ± 1.6 to 4.3 ± 2.4, p<0.001; all ranges of motion p<0.05), while other variables showed no statistically significant differences. All clinical variables were significantly improved in the SA group (p<0.05). However, all clinical scores at the 4-week follow-up showed no significant difference between groups.

CONCLUSIONS

Ultrasound-guided SSNB using proximal approach provides significant pain relief at 4-weeks after treatment, with statistically significant difference when compared with SA, suggesting that SSNB using proximal approach is a potentially useful option in managing shoulder pain. However, in the current study, it was less effective in improving shoulder function and health-related quality of life, compared with SA.

Intra-Articular versus Subacromial Corticosteroid Injection for the Treatment of Adhesive Capsulitis: A Meta-Analysis and Systematic Review

Background

Adhesive capsulitis is one of the most well-known causes of pain and stiffness of the shoulder. Corticosteroid injections have been used for many years. However, it is still controversial where corticosteroid should be injected, whether subacromial or intra-articular.

Objective

The objective of this meta-analysis was to compare the effects of intra-articular (IA) and subacromial (SA) corticosteroid injections for the treatment of adhesive capsulitis.

Materials and Methods

Four foreign databases and two Chinese databases were searched for RCTs and quasi-RCTs involving the comparison of IA and SA corticosteroid injection for the treatment of adhesive capsulitis. The Cochrane risk of bias tool and PEDro score were used to evaluate the quality of the studies. The primary clinical outcomes including VAS, Constant score, ASES score, and ROM were collected. The secondary outcome of corticosteroid-related adverse reactions was also compared between the two groups. The results were evaluated and compared at five time points. Subgroup analyses were performed to further explore the differences between groups.

Results

Eight RCTs and one quasi-RCT, involving 512 participants, were identified and included in this meta-analysis. All studies were of low risk of bias and medium-high quality with the PEDro score ≥5 points. The pooled effect showed that there was no significant difference in the primary outcomes between IA injection and SA injection, with an exception of VAS at 2-3 weeks (P=0.02) and ROM of internal rotation at 8–12 weeks (P=0.02). According to the results of subgroup analyses, the differences of VAS and ROM of internal rotation did not last beyond the 2-3-week time period. Additionally, SA injection had the advantage of avoiding adverse reactions from the corticosteroid, especially in avoiding a large fluctuation of serum blood glucose levels.

Conclusions

When corticosteroid injection is used to treat adhesive capsulitis, both injection sites can be selected. However, due to the scarcity of related studies, more rigorous trials are needed to confirm the current findings.