Corticosteroid injections for painful shoulders

Effectiveness of Ultrasound-Guided Versus Anatomic Landmark-Guided Corticosteroid Injection on Pain, Physical Function, and Safety in Patients With Subacromial Impingement Syndrome: A Systematic Review and Meta-analysis

OBJECTIVE

The aim of the study was to compare the efficacy and safety of ultrasound-guided versus anatomic landmark-guided corticosteroid injection for the treatment of subacromial impingement syndrome.

DESIGN

PubMed, Embase, Web of Science, Cochrane Central Register of Controlled Trials, Scopus, ClinicalTrials.gov , CBM, CNKI, and Wanfang databases were searched from inception to August 15, 2021, for randomized controlled trials comparing ultrasound-guided versus anatomic landmark-guided injections of corticosteroids for the treatment of subacromial impingement syndrome.

RESULTS

Twelve randomized controlled trials with 891 patients were included in this study; 454 patients received ultrasound-guided injections and 437 received anatomic landmark-guided injections. Pooled results showed that ultrasound-guided injection was more beneficial for pain relief (10 trials; mean difference = -0.58; 95% confidence interval = -1.05 to -0.10; P = 0.017) and functional improvement (11 trials; standard mean difference = -0.84; 95% confidence interval = -1.41 to -0.27; P = 0.004). There was no significant difference in shoulder range of motion. In the subgroup analysis, there was a significant difference in pain relief and functional improvement at 6-8 wks and with methylprednisolone.

CONCLUSIONS

Ultrasound-guided injection of corticosteroids is potentially superior to anatomic landmark-guided injection in improving the clinical symptoms of subacromial impingement syndrome; however, these findings should be interpreted with some caution as the quality of evidence was rated as moderate to very low.

Dexamethasone Does not Compensate for Local Anesthetic Cytotoxic Effects on Tenocytes: Morphine or Morphine Plus Dexamethasone May Be a Safe Alternative

Purpose

The purposes of this in vitro study were to investigate whether the addition of dexamethasone can compensate for any cytotoxic effects of the amide-type local anesthetics (LA) bupivacaine and ropivacaine and whether morphine and morphine-6-glucuronide (M6G) may be a safe alternative for peritendinous application.

Methods

Biopsies of human biceps tendons (n = 6) were dissected and cultivated. Cells were characterized by the expression for tenocyte markers, collagen I, biglycan, tenascin C, scleraxis, and RUNX via reverse transcriptase-polymerase chain reaction and immunohistochemistry. Tenocytes were incubated with bupivacaine, ropivacaine, morphine, M6G, or a saline control with and without addition of dexamethasone for 15, 60, or 240 min. Cell viability was determined by quantifying the presence of adenosine-triphosphate.

Results

Significant time-dependent cytotoxic effects were observed for LA after all exposure times. After 15, 60, and 240 minutes, cell viability decreased to 81.1%, 49.4% and 0% (P < .001) for bupivacaine and to 81.4%, 69.6%, and 9.3% (P < .001) for ropivacaine compared to saline control. Dexamethasone did not compensate for these cytotoxic effects. Cell viability was not affected after 15, 60-min exposures to morphine and M6G but decreased significantly (P < .001) after 240 minutes compared to saline control. However, in combination with dexamethasone, tenocyte viability was significantly increased at all times for morphine (P < .01) and at 15 and 60 minutes for M6G (P < .01).

Conclusions

The results showed that amide-type LA have a time-dependent cytotoxic effect on human tenocytes in vitro, which could not be compensated for by dexamethasone, whereas morphine and M6G had no cytotoxic effects on tenocytes after 15 and 60 minutes. The addition of dexamethasone to morphine and M6G had a positive effect on viability, which increased significantly compared to the opioids.

Clinical Relevance

It is known that amide-type local anesthetics used for local joint analgesia have chondrotoxic side-effects. The combined application of morphine and dexamethasone may be a safe alternative.

Evaluation of the effectiveness of dexamethasone iontophoresis in patients with subacromial impingement syndrome

BACKGROUND

Subacromial impingement syndrome is the most common shoulder disease in individuals. There is no study evaluating the effectiveness of steroid iontophoresis in subacromial impingement syndrome. We aimed to assess the effectiveness of dexamethasone iontophoresis as treatment for impingement syndrome with respect to pain and function.

METHODS

Forty-six patients with subacromial impingement syndrome were recruited to the study and divided randomly into two groups (21 patients in iontophoresis group and 25 patients in control group). Demographic, clinical features and MRI findings of patients were recorded. Detailed physical examination of all patients were performed and Numerical rating scale (NRS) during rest and exercise, The Disabilities of the Arm, Shoulder and Hand (DASH) scores were recorded at baseline, week 2 and week 6. Both group received physiotherapy program for ten days. Additionally the patients in iontophoresis group recieved dexamethasone iontophoresis (1 mg dexamethasone per 1 g administered under the active electrode) with an intensity of 0.1-0.2 mA/cm2 galvanic current for ten days.

RESULTS

No significant difference was observed between the groups in terms of gender, job status, MRI findings, painful shoulder and pain duration. Baseline range of motion, Neer, Hawkins, Yocum and painful arc tests, numerical rating scale (NRS) and DASH scores were similar between groups. A significant improvement was found in terms of the NRS (resting and exercise) and DASH scores at week 2 and week 6 in both group (p < 0.001). A significant difference was found in terms of improvement NRS (resting) and DASH scores between baseline and week 6 in iontophoresis group (p = 0.007, p = 0.011 respectively).

CONCLUSIONS

Adding dexamethasone iontophoresis to physiotherapy for patients with subacromial impingement syndrome seems to provide a better clinical and functional improvement.

Predictors of success of corticosteroid injection for the management of rotator cuff disease

BACKGROUND

The use of subacromial corticosteroid injection (CSI) to treat rotator cuff tendinopathy is controversial. We hypothesized that characteristics such as activity level, American Shoulder and Elbow Surgeons (ASES) score, duration of symptoms, and status of the rotator cuff may be prognostic factors for resolution of symptoms postinjection.

METHODS

During a 12-month period, consecutive patients with rotator cuff disease were analyzed. Patients received subacromial CSI, oral NSAIDs, and physical therapy. Baseline ASES score, simple shoulder test, an activity scale, and demographic data were recorded. Patients who remained symptomatic and were indicated for surgery were considered failures. Patients that did not undergo surgery were reassessed after a minimum of 1 year.

RESULTS

Forty-nine patients met our criteria. Follow-up was obtained for 81.6%. Sixteen cases (40%) failed conservative treatment at final follow-up (22.4 ± 11 months). CSI were successful in 76.2% of males and 45% of females (p = 0.04). Full-thickness tears were present in 8% of the patients with symptom resolution and 25% of those that failed conservative treatment (p = 0.29). No significant difference was found in age, hand dominance, duration of symptoms, or any of the scoring systems.

CONCLUSION

It is difficult to predict outcomes after CSI. Our treatment strategy showed a 40% failure rate.

Intra-articular corticosteroid injections versus pulsed radiofrequency in painful shoulder: a prospective, randomized, single-blinded study

OBJECTIVE

Chronic shoulder pain treatment is known to be a difficult and long process. The objective of this study is to compare the efficacy of intra-articular corticosteroid injection and pulse radiofrequency (PRF) applied to the suprascapular nerve in patients with shoulder pain.

METHODS

Fifty patients with shoulder pain were included in the study. Patients were randomly allocated into group 1 (intra-articular injection of corticosteroid) and group 2 (PRF to the suprascapular nerve). Outcome measures included a pain scale (visual analog scale; VAS), range of motion, Shoulder Pain and Disability Index (SPADI), the Short Form-36, Beck Depression Scale questionnaires, and paracetamol consumption.

RESULTS

In both groups, significant improvement was observed in all weeks in VAS, range of motion (active-passive), and SPADI subscores (P<0.05). Improvement was detected in most of the Short Form-36 scores at the end of the treatment in both groups (P<0.05), whereas no significant change was observed in Beck Depression Inventory score (P>0.05). When the groups were compared, a significant difference was found between the groups in favor of group 1 in terms of VAS at night in weeks 1, 4, and 12; VAS at rest in weeks 1 and 4; and VAS during movement in week 1 (P<0.05). There was also a significant difference in favor of group 1 observed in weeks 1, 4, and 12 in SPADI pain and total subscores (P<0.05). Paracetamol consumption was observed to be lower in group 1 (P<0.05).

CONCLUSIONS

Intra-articular injection of corticosteroid and PRF applied to the suprascapular nerve are effective in the treatment of painful shoulder. When 2 treatments are compared, it may be concluded that intra-articular steroid injection was more effective especially in the first weeks regarding pain than the PRF. Further studies are needed to confirm these results in the prospective treatment guidelines.

Methylprednisolone versus triamcinolone in painful shoulder using ultrasound-guided injection

There is little evidence about the comparative efficacy of corticosteroids in the treatment of painful shoulder. The main aim was to compare the efficacy of methylprednisolone (MTP) versus triamcinolone (TMC) in the treatment of painful shoulder using an ultrasound-guided injection. Patients with painful shoulder due to subacromial bursitis and partial or full-thickness rotator cuff tears demonstrated by musculoskeletal ultrasound received a guided-injection of MTP acetate 40 mg (12 patients) or TMC acetonide 40 mg (12 patients). Range of motion and pain visual analogue scale were registered at 10 and 30 min, 1 and 2 weeks postinjection. Two weeks postinjection, both groups reported a mean improvement in range of motion (33%) and relief of pain (61%). Relief of pain of 50% or more was observed in 92% of patients in MTP group and 50% of TMC group (p = 0.02). Two months postinjection, 50% of the patients in MTP group and 25% in TMC group reported total relief of pain (p = 0.3). Patients with painful shoulder receiving an ultrasound-guided injection of MTP or TMC have a rapid and sustained overall response. Relief of pain tends to be more rapid with MTP than TMC.

In vitro optimization of dexamethasone phosphate delivery by iontophoresis

BACKGROUND AND PURPOSE

This study was designed to evaluate the effects of competing ions and electroosmosis on the transdermal iontophoresis of dexamethasone phosphate (Dex-Phos) and to identify the optimal conditions for its delivery.

METHODS

The experiments were performed using pig skin, in side-by-side diffusion cells (0.78 cm(2)), passing a constant current of 0.3 mA via Ag-AgCl electrodes. Dex-Phos transport was quantified for donor solutions (anodal and cathodal) containing different drug concentrations, with and without background electrolyte. Electrotransport of co-ion, citrate, and counterions Na(+) and K(+) also was quantified. The contribution of electroosmosis was evaluated by measuring the transport of the neutral marker (mannitol).

RESULTS

Electromigration was the dominant mechanism of drug iontophoresis, and reduction in electroosmotic flow directed against the cathodic delivery of Dex-Phos did not improve drug delivery. The Dex-Phos flux from the cathode was found to be optimal (transport number of approximately 0.012) when background electrolyte was excluded from the formulation. In this case, transport of the drug is limited principally by the competition with counterions (mainly Na(+) with a transport number of approximately 0.8) and the mobility of the drug in the membrane.

DISCUSSION AND CONCLUSION

Dex-Phos must be delivered from the cathode and formulated rationally, excluding mobile co-anions, to achieve optimal iontophoretic delivery.