Comparison of injection techniques for shoulder pain: results of a double blind, randomised study

The effectiveness of conservative and surgical treatment for shoulder stiffness: a systematic review of current literature

INTRODUCTION

Currently, no therapeutic intervention is universally accepted, and the most effective management for restoring motion and diminishing pain in patients with shoulder stiffness has yet to be defined. This systematic review analyses outcomes of conservative and surgical interventions to treat shoulder stiffness.

SOURCE OF DATA

A systematic review of literature according to the PRISMA guidelines was performed. A comprehensive search of PubMed, Medline, CINAHL, Cochrane, Embase, Ovid and Google Scholar databases using various combinations of the keywords 'shoulder', 'shoulder stiffness', 'stiff shoulder', 'conservative', since inception of databases to June 2018 was performed.

AREAS OF AGREEMENT

Shoulder stiffness could be treated with conservative means including nonsteroidal anti-inflammatory medications, corticosteroid injections, or transcutaneous electrical nerve stimulation, manipulation under anaesthesia, and arthroscopic capsular release.

AREAS OF CONTROVERSY

No therapeutic intervention is universally accepted, and the most effective management to restore motion and diminish pain in patients with shoulder stiffness has yet to be defined.

GROWING POINTS

The rate of failure after treatment for stiff shoulder is higher in the surgical group than in the conservative group.

AREAS TIMELY FOR DEVELOPING RESEARCH

There is insufficient evidence to establish whether surgical or conservative management is the best choice to manage shoulder stiffness. Prospective, randomized studies are needed to establish whether surgical or conservative management produce a clinically relevant difference in functional outcome.

Managing acromio-clavicular joint pain: a scoping review

BACKGROUND

Shoulder pain secondary to acromioclavicular joint pain is a common presentation in primary and secondary care but is often poorly managed as a result of uncertainty about optimal treatment strategies. Osteoarthritis is the commonest cause. Although acromioclavicular pain can be treated non-operatively and operatively, there appears to be no consensus on the best practice pathway of care for these patients, with variations in treatment being common place. The present study comprises a scoping review of the current published evidence for the management of isolated acromioclavicular pain (excluding acromioclavicular joint dislocation).

METHODS

A comprehensive search strategy was utilized in multiple medical databases to identify level 1 and 2 randomised controlled trials, nonrandomised controlled trials and systematic reviews for appraisal.

RESULTS

Four systematic reviews and two randomised controlled trials were identified. No direct studies have compared the benefits or risks of conservative versus surgical management in a controlled environment.

CONCLUSIONS

High-level studies on treatment modalities for acromioclavicular joint pain are limited. As such, there remains little evidence to support one intervention or treatment over another, making it difficult to develop any evidenced-based patient pathways of care for this condition.Level of evidence: 2A.

Corticosteroid injection for adhesive capsulitis in primary care: a systematic review of randomised clinical trials

Adhesive capsulitis is a common cause of shoulder pain and limited movement. The objectives of this review were to assess the efficacy and safety of corticosteroid injections for adhesive capsulitis and to evaluate the optimum dose and anatomical site of injections. PubMed and CENTRAL databases were searched for randomised trials and a total of ten trials were included. Results revealed that corticosteroid injection is superior to placebo and physiotherapy in the short-term (up to 12 weeks). There was no difference in outcomes between corticosteroid injection and oral nonsteroidal anti-inflammatory drugs at 24 weeks. Dosages of intra-articular triamcinolone 20 mg and 40 mg showed identical outcomes, while subacromial and glenohumeral corticosteroid injections had similar efficacy. The use of corticosteroid injections is also generally safe, with infrequent and minor side effects. Physicians may consider corticosteroid injection to treat adhesive capsulitis, especially in the early stages when pain is the predominant presentation.

Evaluation of platelet-rich plasma and fibrin matrix to assist in healing and repair of rotator cuff injuries: a systematic review and meta-analysis

Objective:

To perform a meta-analysis examining the effectiveness of platelet-rich plasma and platelet-rich fibrin matrix for improving healing of rotator cuff injuries.

Data sources/design:

A meta-analysis of eligible studies was performed after searching Medline, Cochrane, and EMBASE on 14 December 2015.

Setting:

University hospital.

Participants:

Patients with rotator cuff injuries.

Review methods/intervention:

Databases were searched using the keywords “PRP or platelet-rich plasma,” “PRFM or platelet-rich fibrin matrix,” “rotator cuff,” and “platelet-rich” for studies comparing outcomes of patients with rotator cuff injuries that did and did not receive a platelet-rich product.

Main measures:

The primary outcome was a functional score change from pre- to post-treatment (Scorepost–Scorepre). The secondary outcome was a visual analogue scale (VAS) pain score change from pre- to post-treatment (VASpost–VASpre).

Results:

A total of 11 studies were included in the meta-analysis. The total number of patients that received platelet-rich plasma or platelet-rich fibrin matrix was 320 and the number of control patients was 318. The standard difference in means of the functional scores was similar between patients administered platelet-rich plasma/fibrin matrix and patients in the control group (standard difference in means for functional scores = 0.029; 95% confidence interval (CI): –0.132 to 0.190; p = 0.725). The standard difference in means was similar between patients administered platelet-rich plasma and the controls (standard difference in means = 0.142; 95% CI: –0.080 to 0.364; p = 0.209).

Conclusion:

The results of this meta-analysis do not support the use of platelet-rich plasma/platelet-rich fibrin matrix in patients with rotator cuff injuries.

Evaluating Clinical Practice Guidelines Based on Their Association with Return to Work in Administrative Claims Data

OBJECTIVE

To examine the association between non-adherence to clinical practice guidelines (CPGs) and time to return to work (RTW) for patients with workplace injuries.

DATA SOURCES/STUDY SETTING

Secondary analysis of medical billing and disability data for 148,199 for shoulder and back injuries from a workers' compensation insurer.

STUDY DESIGN

Cox proportional hazard regression is used to estimate the association between time to RTW and receipt of guideline-discordant care. We test the robustness of our findings to an omitted confounding variable.

DATA COLLECTION

Collected by the insurer from the time an injury was reported, through recovery or last follow-up.

PRINCIPAL FINDINGS

Receiving guideline-discordant care was associated with slower RTW for only some guidelines. Early receipt of care, and getting less than the recommended amount of care, were correlated with faster RTW. Excessive physical therapy, bracing, and injections were associated with slower RTW.

CONCLUSIONS

There is not a consistent relationship between performance on CPGs and RTW. The association between performance on CPG and RTW is difficult to measure in observational data, because analysts cannot control for omitted variables that affect a patient's treatment and outcomes. CPGs supported by observational studies or randomized trials may have a more certain relationship to health outcomes.

High volume image guided injections and structured rehabilitation in shoulder impingement syndrome: a retrospective study

BACKGROUND

the aim was to establish the effect of a high volume-image guided injection and structured rehabilitation (HVIGI&SR) on both pain and function in shoulder impingement syndrome (SIS).

METHODS

44 participants treated between January 2008 and January 2012 with a >3 month history of recalcitrant ultrasound-confirmed SIS were sent a retrospective questionnaire. All participants had received a HVIGI under ultrasound-guidance consisting of 20 mls of Marcaine with 50 mg of hydrocortisone, followed by a period of physiotherapist-led rehabilitation. The validated Shoulder Pain and Disability Index (SPADI) score was used to establish the change in the score between 1 week pre-injection and 3 weeks post-injection, along with an 11-point pain scale.

RESULTS

59% of participants responded. There was a clinically and statistically significant decrease in the SPADI score of 58.7 ± 29.9 (p<0.01). 76% of participants had an improvement in their score of over 50% from their initial score. There was a clinically and statistically significant improvement in pain of 5.19 ± 2.62 (p<0.01) on the numerical rating scale of pain.

CONCLUSION

HVIGI&SR should be considered for short-term treatment of SIS as it showed a significant improvement in both pain and function. A prolonged period of physiotherapist-led rehabilitation can then be undertaken for long term benefits.

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.

Optimal case definitions of upper extremity disorder for use in the clinical treatment and referral of patients

OBJECTIVE

Experts disagree about the optimal classification of upper extremity disorders. To explore whether differential response to treatments offers a basis for choosing between case definitions, we analyzed previously published research.

METHODS

We screened 183 randomized controlled trials (RCTs) of treatments for upper extremity disorders identified from the bibliographies of 10 Cochrane reviews and 4 other systematic reviews, and a search in Medline, Embase, and Google Scholar to June 2010. From these, we selected RCTs that allowed estimates of benefit (expressed as relative risks [RRs]) for >1 case definition to be compared when other variables (treatment, comparison group, followup time, outcome measure) were effectively held constant. Comparisons of RRs for paired case definitions were summarized by their ratios, with the RR for the simpler and broader definition as the denominator.

RESULTS

Two RCT reports allowed within-trial comparison of RRs and 13 others allowed between-trial comparisons. Together these provided 17 ratios of RRs (5 for shoulder treatments, 12 for elbow treatments, and none for wrist/hand treatments). The median ratio of RRs was 1.0 (range 0.3-1.7, interquartile range 0.6-1.3).

CONCLUSION

Although the evidence base is limited, our findings suggest that for musculoskeletal disorders of the shoulder and elbow, clinicians in primary care will often do best to apply simpler and broader case definitions. Researchers should routinely publish secondary analyses for subgroups of patients by different diagnostic features at trial entry to expand the evidence base on optimal case definitions for patient management.

Frozen shoulder

Frozen shoulder is commonly encountered in general orthopaedic practice. It may arise spontaneously without an obvious predisposing cause, or be associated with a variety of local or systemic disorders. Diagnosis is based upon the recognition of the characteristic features of the pain, and selective limitation of passive external rotation. The macroscopic and histological features of the capsular contracture are well-defined, but the underlying pathological processes remain poorly understood. It may cause protracted disability, and imposes a considerable burden on health service resources. Most patients are still managed by physiotherapy in primary care, and only the more refractory cases are referred for specialist intervention. Targeted therapy is not possible and treatment remains predominantly symptomatic. However, over the last ten years, more active interventions that may shorten the clinical course, such as capsular distension arthrography and arthroscopic capsular release, have become more popular. This review describes the clinical and pathological features of frozen shoulder. We also outline the current treatment options, review the published results and present our own treatment algorithm.

Positive outcomes with intra-articular glenohumeral injections are independent of accuracy

BACKGROUND

Shoulder pain is a common, costly, and recalcitrant affliction. One treatment for shoulder pain is intra-articular injection of corticosteroid. Clinical opinion is that injection guided by palpation is accurate and effective, and there is some evidence to support a positive effect of injection on pain. However, great controversy exists as to the accuracy of injection by palpation, whether or not accuracy is important, and what the effect is of accuracy on pain.

METHODS

We used a blinded, longitudinal observational design of effectiveness in an effort to determine the accuracy of intra-articular injections and the effect of that accuracy on pain and functional outcomes in patients with various shoulder pathologies.

RESULTS

Injection accuracy data were captured on 103 patients. Of the 103 blinded injections, 54 received injections that were identified by fluoroscopy as "in" the capsule, whereas 49 were identified as "outside" the capsule; an accuracy rate of 52.4%. In the 4-week follow up, regardless of group assignment or accuracy of the injection, patients improved significantly (P < .01) from pre- to post-injection. Improvement was typically over by 2.5 points in the Numeric Pain Rating Scale (NPRS) categories, over 8 points on the Short-Form McGill Pain Questionnaire (SFMPQ), and over by 13 points on the Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH).

DISCUSSION

Our accuracy rate was within the range reported in the literature. Improvements in all subjects with regard to pain and self-reported function occurred even in light of a wide variance in subject duration of symptoms, multiple injectors with varied training, a blinded approach to injection, and multiple injection approaches.

CONCLUSIONS

The accuracy of the injection does not appear to depend on the experience of the physician and may be irrelevant in treating shoulder pain of multiple origins.

Subacromial impingement syndrome: a prospective comparison of ultrasound-guided versus unguided injection techniques

Objectives

To evaluate the hypothesis that ultrasound-guided subacromial steroid injection produces greater reduction in morbidity than unguided injection.

Design

All patients underwent either ultrasound-guided subacromial injection with 80 mg Depo-Medrone at Bradford Royal Infirmary (group 1) or unguided injection (group 2) by a general practitioner with a specialist interest in musculoskeletal medicine (GPwSI). Patients were clinically and ultrasonically diagnosed with subacromial impingement syndrome.

Setting

Patients in group 1 included both hospital and GP referrals. Patient in group 2 were GP referrals to GPwSI.

Main outcome measures

Comparison was made of pre-injection and six week post-injection Oxford shoulder score and a 0–10 pain score.

Results

Forty-one patients received guided injections (group 1) and 17 unguided (group 2). Group 1 showed a significant mean reduction in the Oxford shoulder score of 9.10 (95% CI 7.07–11.13, P < 0.0001) and a significant change in the mean 0–10 pain score of −3.26 (95% CI −2.51 to −3.88, P < 0.0001). Group 2 also showed significant reduction in the mean Oxford shoulder score of 9.94 (95% CI 6.41–13.47, P < 0.0001) and significant change in the mean 0–10 pain score of −2.94 (−1.95 to −3.93, P < 0.0001). Comparison of groups 1 and 2 for each outcome measure revealed no significant differences.

Conclusion

Our data confirm the efficacy of steroid injection in the management of subacromial impingement, although no significant difference is found when comparing the two groups. We recommend the continued use of unguided injections, with ultrasound used for more practically difficult cases and where there is diagnostic uncertainty.

Subacromial ultrasound guided or systemic steroid injection for rotator cuff disease: randomised double blind study

OBJECTIVE

To compare the effectiveness of ultrasound guided corticosteroid injection in the subacromial bursa with systemic corticosteroid injection in patients with rotator cuff disease.

DESIGN

Double blind randomised clinical trial.

SETTING

Outpatient clinic of a physical medicine and rehabilitation department in Oslo, Norway. Patients 106 patients with rotator cuff disease lasting at least three months.

INTERVENTIONS

Ultrasound guided corticosteroid and lidocaine injection in the subacromial bursa and lidocaine injection in the gluteal region (local group); corticosteroid and lidocaine injection in the gluteal region and ultrasound guided lidocaine injection in the subacromial bursa (systemic group).

MAIN OUTCOME MEASURES

Difference in improvement in the overall shoulder pain and disability index score after six weeks.

RESULTS

Six weeks after the intervention, the mean difference in improvement in overall shoulder pain and disability index score between the local group and the systemic group was -5.2 (95% confidence interval -13.9 to 3.5); it was -4.1 (-12.3 to 4.1, P=0.32) after adjustment for baseline score. A small but statistically significant difference in improvement between groups occurred in favour of the local group for two secondary outcome measures: the Western Ontario rotator cuff index (8.1, 0.7 to 15.6) and change in main complaint (2.0, 0 to 4).

CONCLUSIONS

No important differences in short term outcomes were found between local ultrasound guided corticosteroid injection and systemic corticosteroid injection in rotator cuff disease.

TRIAL REGISTRATION

Clinical trials NCT00640575.

Treatment of tendinopathy: what works, what does not, and what is on the horizon

Tendinopathy is a broad term encompassing painful conditions occurring in and around tendons in response to overuse. Recent basic science research suggests little or no inflammation is present in these conditions. Thus, traditional treatment modalities aimed at controlling inflammation such as corticosteroid injections and nonsteroidal antiinflammatory medications (NSAIDS) may not be the most effective options. We performed a systematic review of the literature to determine the best treatment options for tendinopathy. We evaluated the effectiveness of NSAIDS, corticosteroid injections, exercise-based physical therapy, physical therapy modalities, shock wave therapy, sclerotherapy, nitric oxide patches, surgery, growth factors, and stem cell treatment. NSAIDS and corticosteroids appear to provide pain relief in the short term, but their effectiveness in the long term has not been demonstrated. We identified inconsistent results with shock wave therapy and physical therapy modalities such as ultrasound, iontophoresis and low-level laser therapy. Current data support the use of eccentric strengthening protocols, sclerotherapy, and nitric oxide patches, but larger, multicenter trials are needed to confirm the early results with these treatments. Preliminary work with growth factors and stem cells is promising, but further study is required in these fields. Surgery remains the last option due to the morbidity and inconsistent outcomes. The ideal treatment for tendinopathy remains unclear.

LEVEL OF EVIDENCE

Level II, systematic review.

Effects of hyaluronan on cell proliferation and mRNA expression of procollagens alpha 1 (I) and alpha 1 (III) in tendon-derived fibroblasts from patients with rotator cuff disease: an in vitro study

BACKGROUND

Hyaluronan (HA) improves postoperative recovery after flexor tendon surgery, preventing postoperative adhesion. However, its influence on the rotator cuff tendon after cuff repair has not yet been clarified in detail.

HYPOTHESIS

Hyaluronan is likely to modulate cell proliferation and mRNA expression of procollagens alpha1 (I) and alpha1 (III) in tendon-derived fibroblasts in patients with rotator cuff disease.

STUDY DESIGN

Controlled laboratory study.

METHODS

The study subjects were 10 patients with rotator cuff disease, with an average age of 62 years (range, 44-72). Various concentrations of HA (1.0-5.0 mg/mL) were added to monolayer-cultured tendon-derived fibroblasts from these patients. Hyaluronan binding and CD44 expression on the tendon-derived fibroblasts were evaluated by confocal microscopy using fluorescein-conjugated HA and antihuman CD44 antibody (OS/37). Cell proliferation was evaluated by recording changes in cell number. The levels of expression of procollagen alpha1 (I) and alpha1 (III) mRNA were measured by real-time reverse transcriptase polymerase chain reaction.

RESULTS

Immunofluorescence cytochemistry detected constitutive binding of HA and CD44 expression on the tendon-derived cells. Treatment with various concentrations of HA significantly inhibited cell proliferation and decreased the expression level of procollagen alpha1 (III) mRNA, but not that of procollagen alpha1 (I) mRNA, in the tendon-derived fibroblasts.

CONCLUSION

Hyaluronan modulates cell proliferation and the expression level of procollagen alpha1 (III) mRNA, but not that of pro-collagen alpha1 (I), in fibroblasts from patients with rotator cuff disease.

CLINICAL RELEVANCE

Postoperative use of exogenous HA may allow the healing of a repaired rotator cuff tendon with minimal adhesion.

WITHDRAWN: Interventions for shoulder pain

BACKGROUND

Shoulder pain is a common problem and although there are many accepted standard forms of conservative therapy for shoulder disorders including non-steroidal anti-inflammatory drugs, glucocorticosteroid injections, oral glucocorticosteroid medication, manipulation under anaesthesia, physical therapy, hydrodilatation (distension arthrography) and surgery, evidence of their efficacy is not well established.

OBJECTIVES

To review the efficacy of common interventions for shoulder pain.

SEARCH STRATEGY

We searched the Cochrane Musculoskeletal Group trials register, Cochrane Controlled Trials Register, MEDLINE, EMBASE, CINAHL, and Science Citation Index) up to May 1998, and hand searched major textbooks, bibliographies of relevant literature, the fugitive literature, and the subject indices of relevant journals including: American College of Rheumatology;British College of Rheumatologists; the Biennial Conference of the Manipulative Physiotherapy Association of Australia;International Federation of Manual Therapists conference proceedings; British Orthopaedic Association;and American Orthopaedic Association.

SELECTION CRITERIA

Each identified study was assessed for possible inclusion by two independent reviewers based on the blinded methods sections. The determinants for inclusion were that the trial include an intervention of interest (non-steroidal anti-inflammatory drugs, intra-articular or subacromial glucocorticosteroid injection, oral glucocorticosteroid treatment, physiotherapy, manipulation under anaesthesia, hydrodilatation, or surgery); that treatment allocation was randomized; and that the outcome assessment was blinded.

DATA COLLECTION AND ANALYSIS

Methodological quality was assessed by two independent, blinded reviewers. Data relating to selection criteria, outcome measurement and treatment effect was extracted from the blinded trials. Range of motion scores were entered as degrees of restriction to movement, and all pain and overall effect scores were transformed to 100 point scales. For continuous outcome measures, where standard deviation was not reported it was either calculated from the raw data or converted from standard error of the mean. If neither of these were reported, authors were contacted in an effort to obtain the missing values. Effect sizes were calculated and combined in a pooled analysis if study population, endpoint and intervention were comparable.

MAIN RESULTS

Thirty one trials met inclusion criteria. Mean methodological quality score was 16.8 (9.5 - 22) out of possible score of 40. Selection criteria varied widely even for the same diagnostic label. There was no uniformity in outcome measures used and their measurement properties were rarely reported. Effect sizes for individual trials were small (-1.4 to 3.0). The results of only three studies investigating "rotator cuff tendonitis" could be pooled. Benefit of subacromial steroid injection over placebo for improving range of abduction (weighted difference between means (WMD) 35 degrees , 95% CI 14 to 55) was the only positive finding.

AUTHORS' CONCLUSIONS

There is little evidence to support or refute the efficacy of common interventions for shoulder pain. As well as, the need for further well designed clinical trials, more research is needed to establish a uniform method of defining shoulder disorders and developing outcome measures which are valid, reliable and responsive in these study populations.

Indications for repair of full-thickness rotator cuff tears

Rotator cuff repair surgery for full-thickness tears is common and accepted in orthopaedics today. Given that a significant number of people have asymptomatic rotator cuff tears, the indications for surgery are, however, somewhat unclear. Multiple factors such as duration of symptoms, acuity and size of the tear, patient age, and others require consideration and can influence the decision to perform surgery. This article reviews these variables and the indications for surgery to repair full-thickness rotator cuff tears.

Indications for rotator cuff repair: a systematic review

Despite the popularity of surgical repair of rotator cuff tears, literature regarding the indications for and timing of surgery are sparse. We performed a systematic review of the literature to investigate factors influencing the decision to surgically repair symptomatic, full-thickness rotator cuff tears. Specifically, how do demographic variables, duration of symptoms, timing of surgery, physical examination findings, and size of tear affect treatment outcome and indications for surgery? We reviewed the best available evidence, which offers some guidelines for surgical decision making. Variables suggest earlier surgical intervention may be needed in the setting of weakness and substantial functional disability. With regard to demographic variables, the evidence is unclear regarding their association with treatment outcome. However, older chronological age does not seem to portend a worse outcome. Pending worker's compensation claims does seem to negatively affect treatment results. Further research is required to define the indications for surgery for full thickness rotator cuff tears. However, the design and conduct of an ethical study to obtain Level I evidence on this issue will be a major challenge.

Diagnosis of shoulder pain by history and selective tissue tension: agreement between assessors

STUDY DESIGN

Evaluation of agreement between assessors.

OBJECTIVE

To evaluate agreement between an expert in selective tissue tension (STT) and 3 other trained assessors, all using STT in conjunction with a preliminary clinical history, on their diagnostic labelling of painful shoulders.

BACKGROUND

Consensus on diagnostic labelling for shoulder pain is poor, hampering interpretation of the evidence for interventions. STT, a systematic approach to physical examination and diagnosis, offers potential for standardization, but its reliability is contentious.

METHODS AND MEASURES

Four trained assessors, 1 of whom was considered an expert, separately assessed 56 painful shoulders in 53 subjects (32 male [mean+/-SD age, 51+/-13 years], 21 female [mean+/-SD age, 57+/-12 years]), using STT in conjunction with a preliminary clinical history. Assessors labelled each painful shoulder as "rotator cuff lesion," "bursitis," "capsulitis," "other diagnosis," or "no diagnosis." Combinations of diagnoses were allowed.

RESULTS

A diagnosis was made in every case, with less than 7% of the diagnoses being combined. With the diagnostic categories pooled, agreement (kappa and 95% confidence interval [CI]) between the expert assessor and each of the other assessors was good, ranging from 0.61 (0.44-0.78) to 0.75 (0.60-0.90). For single diagnostic categories, agreement between the expert and each of the others (dichotomized data) ranged from 0.35 (-0.03-0.73) to 0.58 (0.29-0.87) for bursitis; 0.63 (0.40-0.86) to 0.82 (0.65-0.99) for capsulitis; 0.71 (0.49-0.93) to 0.79 (0.61-0.96) for rotator cuff lesions; and from 0.69 (0.35-1.00) to 0.78 (0.48-1.00) for other diagnoses.

CONCLUSIONS

Overall, STT in conjunction with a preliminary clinical history enables good agreement between trained assessors. Future work is required to evaluate its criterion validity.

The stiff shoulder

Shoulder stiffness is a common but poorly understood disorder of the glenohumeral joint. Many terms are used to describe a stiff shoulder, including frozen shoulder and adhesive capsulitis. This article reviews the terminology, classification, diagnostic options, and management options of shoulder stiffness. Conservative measures,emphasizing a four-quadrant stretching program, typically produce effective treatment outcomes. Operative interventions, which may be required for the small percentage of patients who fail conservative therapy, are also presented.

Shoulder injections for osteoarthritis and other disorders

Shoulder injection procedures are powerful diagnostic and therapeutic tools for the care of patients with osteoarthritis and other pathologic conditions of the shoulder-girdle region. Although questions regarding many of the details of the specific procedures still need to be answered, a modest body of literature is available. The musculoskeletal physiatrist is in a good position to contribute to this knowledge base through further clinical research.

Diagnostic value of physical tests for isolated chronic acromioclavicular lesions

PURPOSE

Chronic acromioclavicular joint lesions are a common source of pain and disability in the shoulder. The goal of this study was to evaluate diagnostic values of physical tests for isolated, chronic acromioclavicular joint lesions.

STUDY DESIGN

A retrospective case-control study.

METHODS

Between 1994 and 2002, 35 patients underwent a distal clavicle excision for isolated acromioclavicular joint lesions. The results of 3 commonly used examinations for acromioclavicular joint lesions were calculated for sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy.

RESULTS

The cross body adduction stress test showed the greatest sensitivity (77%), followed by the acromioclavicular resisted extension test (72%) and active compression test (41%). The active compression test had the greatest specificity (95%). All tests had a negative predictive value of greater than 94%, but the positive predictive value was less than 30% for all tests. The active compression test had the highest overall accuracy (92%), followed by the acromioclavicular resisted extension test (84%) and the cross arm adduction stress test (79%). Combinations of the tests increased the diagnostic values for chronic acromioclavicular joint lesions.

CONCLUSIONS

These tests have utility in evaluating patients with acromioclavicular joint pathologic lesions, and a combination of these physical tests is more helpful than isolated tests.

Regional musculoskeletal conditions: shoulder pain

About half the population has at least one episode of shoulder pain yearly. History and clinical examination are cornerstones in the evaluation of the patient. Shoulder pain at the work place is associated with job strain: lack of control and work with elevated arms and hand tools. Clinical skills and knowledge about red and yellow flags and biomechanics are essential to perform a systematic and reliable evaluation. The diagnostic validity of clinical tests for rotator cuff tear, impingement syndrome and superior labral tears is equal or better than ultrasound and magnetic resonance imaging. Non-steroidal anti-inflammatory drugs and cortico-steroidal injections have documented short-term pain relief. Additionally, the physician should attempt to give the patient simple advice and reinforce active coping strategies. One randomized study suggests that a proper physiotherapy regimen and surgery are equally effective for the impingement syndrome. Further research should address the cost-effectiveness of diagnostic methods and treatments.

Corticosteroid injections for shoulder pain

BACKGROUND

While many treatments, including corticosteroid injections in and around the shoulder, are advocated to be of benefit for shoulder pain, few are of proven efficacy. This review of corticosteroid injections for shoulder pain is one in a series of reviews of varying interventions for shoulder disorders.

OBJECTIVES

To determine the efficacy and safety of corticosteroid injections in the treatment of adults with shoulder pain.

SEARCH STRATEGY

MEDLINE, EMBASE, CINAHL, Central and Science Citation Index were searched up to and including June 2002.

SELECTION CRITERIA

Randomised and pseudo-randomised trials in all languages of corticosteroid injections compared to placebo or another intervention, or of varying types and dosages of steroid injection in adults with shoulder pain. Specific exclusions were duration of shoulder pain less than three weeks, rheumatoid arthritis, polymyalgia rheumatica and fracture.

DATA COLLECTION AND ANALYSIS

Trial inclusion and methodological quality was assessed by two independent reviewers according to predetermined criteria. Results are presented separately for rotator cuff disease, adhesive capsulitis, full thickness rotator cuff tear and mixed diagnoses, and, where possible, combined in meta-analysis.

MAIN RESULTS

Twenty-six trials met inclusion criteria. The number, site and dosage of injections varied widely between studies. The number of participants per trial ranged from 20 to 114 (median 52 participants). Methodological quality was variable. For rotator cuff disease, subacromial steroid injection was demonstrated to have a small benefit over placebo in some trials however no benefit of subacromial steroid injection over NSAID was demonstrated based upon the pooled results of three trials. For adhesive capsulitis, two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was insufficient data for pooling of any of the trials. One trial suggested short-term benefit of intra-articular corticosteroid injection over physiotherapy in the short-term (success at seven weeks RR=1.66 (1.21, 2.28).

REVIEWER'S CONCLUSIONS

Despite many RCTs of corticosteroid injections for shoulder pain, their small sample sizes, variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment. Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained. There is a need for further trials investigating the efficacy of corticosteroid injections for shoulder pain. Other important issues that remain to be clarified include whether the accuracy of needle placement, anatomical site, frequency, dose and type of corticosteroid influences efficacy.

The targeting accuracy of subacromial injection to the shoulder: an arthrographic evaluation

PURPOSE

The study goal was to examine the targeting accuracy of subacromial injection to the shoulder and the influence of the location of the injected structure.

TYPE OF STUDY

A prospective nonrandomized study.

METHODS

Fifty-three patients (56 shoulders; 34 women and 19 men; mean age, 74.5 years; range, 49 to 91) with impingement signs (Neer, Hawkins) of at least 2 months' duration received a subacromial injection of a mixture of 0.5 mL (2.5 mg) betamethasone acetate and 3 mL of radiographic contrast material (iotrolan) and 7 mL of 1% lidocaine using a lateral approach. Radiographs of the shoulder joint were taken immediately after the injection to determine the structure reached by the injection. Details of pain expressed as Neer and Hawkins impingement signs were obtained before and 15 minutes after the injection, and subjectively assessed using a 4-point self-administered pain score. Pain reduction resulting from subacromial and intradeltoid injection was compared.

RESULTS

Thirty-nine of the 56 injections (70%) were judged to have reached the subacromial bursa. Twelve (21%) were seen to have entered the deltoid muscle; 2 (4%) were in the glenohumeral joint; and 3 (5%) were subcutaneous. A comparison of subacromial bursal with intradeltoid injection showed no significant differences in pain reduction expressed as impingement signs (1.5 vs 1.7 in the Neer impingement sign and 1.6 vs 1.6 in the Hawkins impingement sign, respectively).

CONCLUSIONS

This study showed that subacromial injection was a relatively difficult procedure. A high incidence of injections that missed the subacromial bursa would be a sufficient reason to refrain from repeated usage of corticosteroids. These results also suggest that pain relief could be attained whether the injected material reached the subacromial bursa or the deltoid muscle. Successful pain relief after intradeltoid injection seems to call into question the diagnostic value of a positive Neer impingement test.

Needling therapies in the management of myofascial trigger point pain: a systematic review

OBJECTIVE

To establish whether there is evidence for or against the efficacy of needling as a treatment approach for myofascial trigger point pain.

DATA SOURCES

PubMed, Ovid MEDLINE, Ovid EMBASE, the Cochrane Library, AMED, and CISCOM databases, searched from inception to July 999.

STUDY SELECTION

Randomized, controlled trials in which some form of needling therapy was used to treat myofascial pain.

DATA EXTRACTION

Two reviewers independently extracted data concerning trial methods, quality, and outcomes.

DATA SYNTHESIS

Twenty-three papers were included. No trials were of sufficient quality or design to test the efficacy of any needling technique beyond placebo in the treatment of myofascial pain. Eight of the 10 trials comparing injection of different substances and all 7 higher quality trials found that the effect was independent of the injected substance. All 3 trials that compared dry needling with injection found no difference in effect.

CONCLUSIONS

Direct needling of myofascial trigger points appears to be an effective treatment, but the hypothesis that needling therapies have efficacy beyond placebo is neither supported nor refuted by the evidence from clinical trials. Any effect of these therapies is likely because of the needle or placebo rather than the injection of either saline or active drug. Controlled trials are needed to investigate whether needling has an effect beyond placebo on myofascial trigger point pain.

Clinical evaluation of sodium hyaluronate for the treatment of patients with rotator cuff tear

A randomized study of two types of conservative treatment of 78 shoulders in 78 patients with rotator cuff tears was performed. Twenty-five milligrams of sodium hyaluronate (SH) was injected into shoulders in one group (SH group) and 2 mg of dexamethasone was injected in the other group (steroid group). Injection of each drug was planned for once per week for 5 consecutive weeks. In the SH group, University of California at Los Angeles score before treatment was 13.6 +/- 2.6 points in 16 patients who did not require surgery (satisfied patients) and 12.8 +/- 3.5 points in 22 patients who required surgery (unsatisfied patients) (not statistically significant). In the steroid group, University of California at Los Angeles score before treatment was 11.9 +/- 3.6 points for 15 satisfied patients and 12.6 +/- 3.9 points for 25 unsatisfied patients (again, not statistically significant). In the SH group, the score at 4 weeks after treatment for satisfied patients increased to 27.6 +/- 3.1 points, whereas that for unsatisfied patients was 14.9 +/- 1.2 points (P <.0001). Similarly, in the steroid group, the score at 4 weeks after the treatment for satisfied patients increased to 26.5 +/- 2.0 points, whereas that for unsatisfied patients was 15.0 +/- 4.0 points (P <.0001). At 24 weeks after treatment, the score for satisfied patients was 26.2 +/- 3.1 points in the SH group and 25.3 +/- 2.5 points in the steroid group. The effective rate of the SH group was 39.5% and that of the steroid group was 35%. Therapeutic efficacy in the SH group was equivalent to that in the steroid group. In both groups, the rate of patients who engaged in manual labor was significantly higher in the group of unsatisfied patients than in that of satisfied patients. No adverse reaction to either treatment was observed. These results suggest that SH is an effective conservative treatment for patients with rotator cuff tears.

The Southampton examination schedule for the diagnosis of musculoskeletal disorders of the upper limb

OBJECTIVES

Following a consensus statement from a multidisciplinary UK workshop, a structured examination schedule was developed for the diagnosis and classification of musculoskeletal disorders of the upper limb. The aim of this study was to test the repeatability and the validity of the newly developed schedule in a hospital setting.

METHOD

43 consecutive referrals to a soft tissue rheumatism clinic (group 1) and 45 subjects with one of a list of specific upper limb disorders (including shoulder capsulitis, rotator cuff tendinitis, lateral epicondylitis and tenosynovitis) (group 2), were recruited from hospital rheumatology and orthopaedic outpatient clinics. All 88 subjects were examined by a research nurse (blinded to diagnosis), and everyone from group 1 was independently examined by a rheumatologist. Between observer agreement was assessed among subjects from group 1 by calculating Cohen's kappa for dichotomous physical signs, and mean differences with limits of agreement for measured ranges of joint movement. To assess the validity of the examination, a pre-defined algorithm was applied to the nurse's examination findings in patients from both groups, and the sensitivity and specificity of the derived diagnoses were determined in comparison with the clinic's independent diagnosis as the reference standard.

RESULTS

The between observer repeatability of physical signs varied from good to excellent, with kappa coefficients of 0.66 to 1.00 for most categorical observations, and mean absolute differences of 1.4 degrees -11.9 degrees for measurements of shoulder movement. The sensitivity of the schedule in comparison with the reference standard varied between diagnoses from 58%-100%, while the specificities ranged from 84%-100%. The nurse and the clinic physician generally agreed in their diagnoses, but in the presence of shoulder capsulitis the nurse usually also diagnosed shoulder tendinitis, whereas the clinic physician did not.

CONCLUSION

The new examination protocol is repeatable and gives acceptable diagnostic accuracy in a hospital setting. Examination can feasibly be delegated to a trained nurse, and the protocol has the benefit of face and construct validity as well as consensus backing. Its performance in the community, where disease is less clear cut, merits separate evaluation, and further refinement is needed to discriminate between discrete pathologies at the shoulder.

Interventions for shoulder pain

OBJECTIVES

To review the efficacy of common interventions for shoulder pain.

SEARCH STRATEGY

We searched the Cochrane Musculoskeletal Group trials register, Cochrane Controlled Trials Register, Medline, Embase, Cinahl, and Science Citation Index) up to May 1998, and hand searched major textbooks, bibliographies of relevant literature, the fugitive literature, and the subject indices of relevant journals including: American College of Rheumatology;British College of Rheumatologists; the Biennial Conference of the Manipulative Physiotherapy Association of Australia;International Federation of Manual Therapists conference proceedings; British Orthopaedic Association;and American Orthopaedic Association.

SELECTION CRITERIA

Each identified study was assessed for possible inclusion by two independent reviewers based on the blinded methods sections. The determinants for inclusion were that the trial include an intervention of interest (non-steroidal anti-inflammatory drugs, intra-articular or subacromial glucocorticosteroid injection, oral glucocorticosteroid treatment, physiotherapy, manipulation under anaesthesia, hydrodilatation, or surgery); that treatment allocation was randomized; and that the outcome assessment was blinded.

DATA COLLECTION AND ANALYSIS

Methodological quality was assessed by two independent, blinded reviewers. Data relating to selection criteria, outcome measurement and treatment effect was extracted from the blinded trials. Range of motion scores were entered as degrees of restriction to movement, and all pain and overall effect scores were transformed to 100 point scales. For continuous outcome measures, where standard deviation was not reported it was either calculated from the raw data or converted from standard error of the mean. If neither of these were reported, authors were contacted in an effort to obtain the missing values. Effect sizes were calculated and combined in a pooled analysis if study population, endpoint and intervention were comparable.

MAIN RESULTS

Thirty one trials met inclusion criteria. Mean methodological quality score was 16.8 (9.5 - 22) out of possible score of 40. Selection criteria varied widely even for the same diagnostic label. There was no uniformity in outcome measures used and their measurement properties were rarely reported. Effect sizes for individual trials were small (-1.4 to 3. 0). The results of only three studies investigating rotator cuff tendonitis could be pooled. Benefit of subacromial steroid injection over placebo for improving range of abduction (weighted difference between means (WMD) 35 degrees, 95% CI 14 to 55) was the only positive finding.

REVIEWER'S CONCLUSIONS

There is little evidence to support or refute the efficacy of common interventions for shoulder pain. As well as, the need for further well designed clinical trials, more research is needed to establish a uniform method of defining shoulder disorders and developing outcome measures which are valid, reliable and responsive in these study populations.

Long-term effectiveness of translational manipulation for adhesive capsulitis

Long term effects of glenohumeral joint translational (gliding) manipulation on range of motion, pain, and function in patients with adhesive capsulitis were studied. Thirty-one patients underwent brachial plexus block followed by translational manipulation of the glenohumeral joint. Changes in range of motion and pain were assessed before manipulation with the patient under anesthesia, immediately after manipulation with the patient still under anesthesia, at early followup (5.3 +/- 3.2 weeks), and at long term followup (14.4 +/- 7.3 months). Passive range of motion increased significantly for flexion, abduction, external rotation, and internal rotation. Significant decreases in visual analog pain scores between initial evaluation and the followup assessments also occurred. Furthermore, Wolfgang's criteria score increased significantly between initial evaluation and followup assessments. Translational manipulation provides a safe, effective treatment option for adhesive capsulitis.

Shoulder pain in older people

Shoulder pain is encountered commonly in older people. Most of the conditions are amenable to nonoperative treatment, but a clear understanding of the anatomy and those conditions encountered most commonly is essential. A careful history and physical examination, as well as limited diagnostic tests, point to a clear diagnosis in the majority of patients. Most often, conservative measures are effective. Steroid injections are often helpful for both diagnostic and therapeutic reasons. A small percentage of patients do not respond to conservative management and require operative intervention.

The diabetic frozen shoulder: arthroscopic release

Seventeen patients who were diabetics developed frozen shoulders which failed to respond to conservative management. They had persistent pain, stiffness, and limited function. An arthroscopic release was performed by progressively releasing the anterior structures from superior to inferior. Starting from the interval area we progressed to the anterior superior glenohumeral ligament, the intra-articular portion of the subscapularis, the anterior capsule, and the inferior capsule. Postoperatively physiotherapy was carried out daily to maintain the range of movement. At a follow up of 1 to 5 years the patients were assessed using the American Shoulder Society scheme. In addition the patients were assessed preoperatively and postoperatively on four criteria; pain, external rotation, abduction, and function. We found that the patients were statistically significantly improved in all four categories. Thirteen of the 17 patients had no pain, full range of motion compared with the opposite side, and full function. There was one poor result with no improvement. The remaining three patients had improved but still had residual abnormalities. We consider arthroscopic release to be an effective treatment for the resistant diabetic frozen shoulder.

Efficacy of injections of corticosteroids for subacromial impingement syndrome

A prospective, randomized, controlled, double-blind clinical study was performed to determine the short-term efficacy of subacromial injection of corticosteroids for the treatment of subacromial impingement syndrome. Forty patients were randomized to receive either six milliliters of 1 per cent lidocaine without epinephrine (the control group) or two milliliters containing forty milligrams of triamcinolone acetonide per milliliter with four milliliters of 1 per cent lidocaine without epinephrine (the corticosteroid group). The patients were re-examined serially until completion of the study. Nineteen patients, whose mean age was fifty-six years (range, thirty-two to eighty years), were randomized to the corticosteroid group, and twenty-one patients, whose mean age was fifty-seven years (range, thirty-two to eighty-one years), were randomized to the control group. The mean duration of symptoms before the injection was eight months for both groups. Eighteen patients in the corticosteroid group and nineteen patients in the control group had moderate or severe pain before the injection. At the most recent follow-up evaluation, at a mean of thirty-three weeks for the corticosteroid group and twenty-eight weeks for the control group, three patients in the corticosteroid group had moderate or severe pain, compared with fifteen patients in the control group. The mean active range of forward elevation and external rotation improved by 24 and 11 degrees, respectively, for the corticosteroid group and by 10 and 5 degrees, respectively, for the control group. We concluded that subacromial injection of corticosteroids is an effective short-term therapy for the treatment of symptomatic subacromial impingement syndrome. The use of such injections can substantially decrease pain and increase the range of motion of the shoulder.

Steroid injections for shoulder disorders: a systematic review of randomized clinical trials

BACKGROUND

Patients with shoulder disorders are believed to benefit considerably from steroid injections. However, the controversy about their efficacy persists.

AIM

The study was designed to assess the efficacy of steroid injections for shoulder disorders.

METHOD

A systematic computerized literature search in Medline (Index Medicus 1/1966-10/1995) and Embase (Excerpta Medica 1/1984-10/1995) was conducted, supplemented with citation tracking of all relevant publications. Studies published before November 1995 were selected if steroid injections were randomly allocated to patients with shoulder disorders and when clinically relevant outcome measures were reported. Because the validity of study outcomes depends heavily on the strength of methodological quality, the methods were assessed systematically by two 'blinded' independent reviewers. This resulted in a method score (maximum 100 points) that was based on four categories: study population, interventions, measurement of effect, and data presentation and analysis. Confidence intervals for the differences between groups in success rates were calculated in order to summarize the efficacy of steroid injections.

RESULTS

Only three out of the 16 studies scored more than 50 points, indicating a generally poor quality of methods. Most studies reported small sample sizes. The flaws most often found were incomparability of co-interventions and poor blinding of therapist. The methods assessment was frequently hampered by incomplete information about randomization, prognostic comparability, compliance, outcome measures included, blinding of patients and blinding of outcome measurement.

CONCLUSIONS

The evidence in favour of the efficacy of steroid injections for shoulder disorders is scarce. The methods of most studies appear to be of poor quality. The few studies that appear to be credible do not provide conclusive evidence about which patients at what time in the course of shoulder disorders benefit most from steroid injections.

Classification systems of soft tissue disorders of the neck and upper limb: do they satisfy methodological guidelines?

A critical appraisal of existing classifications of soft tissue disorders of the neck and upper limb was performed utilizing methodological criteria including appropriateness for purpose, validity, reliability, feasibility, and generalizability. Five classifications were assessed independently by three raters using standardized forms. For those criteria that can be assessed by inspection of the classification itself, none of the classification systems appeared acceptable for reasons such as failure to be comprehensive, overlap of categories, and lack of demonstration that the criteria for inclusion into the categories are valid and reliable. No judgement could be passed about those criteria that require formal testing, such as reliability and construct validity, because of the absence of data. The overall interrater reliability of the critical appraisal was high, with an intraclass correlation coefficient of 0.82. The validity of studies that have relied upon existing classifications of soft tissue disorders of the neck and upper limb to group the entities under study is questioned in light of the findings of this study. Future work should be directed toward improving existing classification systems and/or developing new ones that fulfil basic measurement criteria.

Frozen shoulder syndrome: a review of literature

Physical therapists in a variety of settings treat individuals with frozen shoulder syndrome. Frozen shoulder syndrome is a condition in which a soft tissue glenohumeral capsular lesion is accompanied by painful and restricted active and passive shoulder motion. Despite its common occurrence, there is a significant knowledge void concerning frozen shoulder syndrome and its treatment. The purpose of this paper was to review the literature and to advance clear, current information regarding the clinical manifestations of frozen shoulder syndrome; its natural history; and views regarding pathogenesis, pathophysiology, and treatment. Further research is necessary to elucidate a clear, factual basis for therapeutic interventions.

Frozen shoulder

The frozen shoulder is a common cause of shoulder pain and disability. Most patients slowly improve over 12 to 24 months. Some have prolonged loss of movement, pain, and associated disability. Treatments include physiotherapy, corticosteroid injections, and manipulation. Clinical trials of these treatments have produced conflicting results.

Low power laser therapy of shoulder tendonitis

30 patients with supraspinatus or bicipital tendonitis were randomly allocated to active infrared laser therapy at 904 nm three times weekly for 2 weeks, dummy laser or drug treatment for 2 weeks. Objectively maximum active extension, flexion and abduction of the shoulder, and subjectively pain stiffness movement and function were measured at 0 and 2 weeks. Significant improvement of active over dummy laser was noted for all seven assessments. Active laser therapy produced significant improvement over drug therapy for all three objective measures and pain. Naproxen sodium significantly improved only movement and function compared to dummy laser. These results demonstrate the effectiveness of laser therapy in tendonitis of the shoulder.