Intra-articular triamcinolone acetonide injection in patients with capsulitis of the shoulder: a comparative study of two dose regimens

What volume of injection should be used in hydrodilatation for frozen shoulder? A prospective cohort study

This study evaluated the outcome and recurrence rates after hydrodilatation (HD) in patients with frozen shoulder (FS), comparing the effects of injecting 25 mL or more of fluid versus lower volumes. A total of 132 shoulders (130 patients) were treated at a shoulder clinic between August 2019 and February 2023. HD was performed under ultrasound guidance, injecting a combination of 40 mg Triamcinolone, 10 mL of local anaesthetic, and saline to a total volume of 10 to 40 mL based on patient tolerance. The results were analysed based on the volume of fluid injected and whether patients were diabetic. The overall failure or recurrence rate (FRR) was 24% after a minimum of 1 year. Non-diabetic patients injected with ≥25 mL had a significantly lower FRR (9%) compared to those injected with <25 mL (30%, p = 0.006). Diabetic patients had a much higher FRR of 52%, compared to 17% in non-diabetics (p = 0.0002). The study concluded that injecting patients with ≥25 mL of fluid had a significantly lower FRR than those injected with <25 mL at a minimum of 12 months follow-up (9% vs 30%, p = 0.006). Diabetic patients experienced a higher rate of recurrence, suggesting the need for patient counselling about the increased likelihood of failure.

Study of Functional Outcome of Intra-articular Steroid Injection and Manipulation of Shoulder Joints in Frozen Shoulder

INTRODUCTION

Frozen shoulder, also known as adhesive capsulitis, is characterized by the insidious onset of pain and progressive loss of global active and passive mobility of the glenohumeral joint, which can be treated by non-surgical or surgical methods. This study was done to evaluate the functional outcome of intra-articular (I/A) steroid injection and manipulation of the shoulder joint manipulation under anesthesia (MUA) in frozen shoulder.

METHODS

A cross-sectional study was done in a tertiary care hospital in Pokhara, Nepal. A total of 35 patients over 40 years were included in the study. All the patients underwent I/A steroid injection and MUA. The functional outcome was evaluated using a Constant-Murley shoulder score (CSS) and a visual analogue scale (VAS) scoring system.

RESULT

The mean age was 53.46±7.524 years. Twenty-two were female, while 13 were male. Twelve patients were associated with diabetes. Minor complications were noted in 15 patients (14 with transient pain and one with facial flushing). At 12 weeks, the mean VAS score was 2.16±1.33 cm, and the mean CSS score was 82.66±7.008. At 24 weeks, the mean VAS was 1.534±1.195 cm, and the mean CSS score was 85.77±6.998.

CONCLUSION

This study shows that patients with frozen shoulder treated with I/A steroid injection and MUA give excellent functional outcomes in most patients.

Rotator Interval vs Posterior Approach Ultrasound-guided Corticosteroid Injections in Primary Frozen Shoulder: A Meta-analysis of Randomized Controlled Trials

OBJECTIVE

To compare the efficacy of rotator interval (RI) vs posterior approach (PA) ultrasound (US) guided corticosteroid injections into the glenohumeral (GH) joint in primary frozen shoulder (PFS).

DATA SOURCES

A systematic literature search for all relevant studies on Medline, Scopus, Embase, Web of Science, and Cochrane Central, up to January 2023 was conducted.

STUDY SELECTION

Randomized controlled trials that directly compared the US-guided corticosteroid injection into the RI and GH joint using PA in patients clinically and radiographically diagnosed with PFS.

DATA EXTRACTION

The primary outcome was pain, and the secondary outcomes were function, and range of motion (ROM). Two authors independently assessed the risk of bias using the Cochrane risk-of-bias tool version 2. A random-effects model and generic inverse variance method were performed. Effect sizes were estimated using mean difference (MD) and standardized mean difference (SMD).

DATA SYNTHESIS

A total of 5 clinical trials involving 323 subjects were included for the meta-analysis. US-guided corticosteroid injections into the RI revealed significant pain relief (MD 1.33 [95% confidence interval (CI) 0.20 to 2.46]; P=.02) and significant functional improvement (SMD 1.31 [95% CI 0.11 to 2.51]; P=.03) compared with the PA after 12 weeks.

CONCLUSION

The results suggest the injection of corticosteroid into RI space is more effective than PA after 12 weeks in improving both pain and functional scores in patients with PFS.

Corticosteroid Injection Methods for Frozen Shoulder: A Network Meta-analysis

OBJECTIVE

To investigate the efficacy of corticosteroid (CS) injection methods for frozen shoulder.

DATA SOURCES

PubMed, Embase, and Cochrane Library were searched up to May 6, 2023.

STUDY SELECTION

Randomized controlled trials (RCTs) that investigated CS injection methods for frozen shoulder were included.

DATA EXTRACTION

Data were extracted independently by 2 authors. Risk of bias was assessed using the RoB 2 tool.

DATA SYNTHESIS

A random-effects network meta-analysis was performed within a frequentist framework. The certainty of evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluations approach. A total of 66 RCTs involving 4491 patients were included. For short-term outcomes, 4-site injection (vs placebo [PLA]: standardized mean difference [SMD]=-2.20, 95% confidence interval [CI], -2.81 to -1.59 in pain; SMD=2.02; 95% CI, 1.39-2.65 in global function) was the most effective (low certainty). Rotator interval injection was the optimal treatment with moderate to high certainty (vs PLA: SMD=-1.07, 95% CI, -1.51 to -0.64 in pain; SMD=0.94, 95% CI, 0.49-1.40 in global function). For midterm outcomes, 4-site injection was most effective (vs PLA: SMD=-1.71, 95% CI, -2.41 to -1.01 in pain; SMD=2.22, 95% CI, 1.34-3.09 in global function; low certainty). Distension via rotator interval (D-RI) was the optimal treatment with moderate to high certainty (vs PLA: SMD=-1.10, 95% CI, -1.69 to -0.51 in pain; SMD=1.46, 95% CI, 0.73-2.20 in global function). Distension and intra-articular injection via anterior or posterior approaches produced effects equivalent to those of rotator interval injection and D-RI.

CONCLUSIONS

Rotator interval injection, distension, and intra-articular injection had equivalent effects on symptom relief. More RCTs are required to validate the superiority of multisite injections.

Recurrence of the frozen shoulder after hydrodilatation, what is the true incidence?

Purpose of the study

To assess the outcome and recurrence rates of frozen shoulder treated by hydrodilatation in an independent hospital setting.

Method

Patients presenting to a shoulder clinic from August 2019 to July 2021 with a diagnosis of frozen shoulder were offered hydrodilatation. Data included primary or secondary frozen shoulder, length of symptoms, and diabetic status. An Oxford Shoulder Score was completed prior to hydrodilatation. Using ultrasound guidance, 40 mg Triamcinolone and local anaesthetic (10-25 mL depending on patient tolerance) were injected into the rotator interval. At a mean of 9 months, patients recorded their tolerance of the procedure, subsequent progress, the need for further treatment, and their current Oxford Shoulder Score.

Results

From 55 shoulders, six patients had a failure to improve and 10 patients had a transient improvement followed by recurrence (29%). 2/21 (9.5%) patients had 25 mL injected compared to 14/34 (41%) who had < = 20 mL (p = 0.012). 14/43 (33%) of primary frozen shoulder patients had a recurrence, compared with 2/12 (16%) secondary frozen shoulder patients, p = 0.019.

Conclusion

Further treatment was indicated in 14/34 (41%) of patients who underwent hydrodilatation in the frozen stage of frozen shoulder and could not tolerate more than 20 mL of injection, and was more commonly required in primary (33%) versus secondary (16%) frozen shoulder.

Effectiveness of Pharmacopuncture Therapy in Adhesive Capsulitis: a Study Protocol for a Pragmatic Randomized Controlled Trial

Background

Adhesive capsulitis is a progressive, idiopathic disorder that significantly impacts individuals̓ daily lives and increases their medical burden. Pharmacopuncture therapy, which combines acupuncture techniques with herbal medicine, involves injecting herbal extracts into specific acupoints. This study aims to determine the effectiveness and safety of pharmacopuncture therapy in comparison to physiotherapy (PT) for treating adhesive capsulitis.

Methods

This research protocol outlines a two-arm, parallel, multi-center, pragmatic randomized controlled trial. Fifty participants will be randomly allocated to either the pharmacopuncture therapy or PT group, and they will receive 12 sessions of their respective therapies over a 6-week period. The primary outcome measure is the numeric rating scale for shoulder pain. Secondary outcomes include the visual analog scale score for shoulder pain, Shoulder Pain and Disability Index, Patients̓ Global Impression of Change score, Short Form-12 Health Survey Version 2 score, and EuroQol-5 Dimension. Statistical analysis will be conducted based on the intention-to-treat principle.

Discussion

This trial may offer high-quality and reliable clinical evidence for evaluating the effectiveness and safety of pharmacopuncture therapy compared to PT in the treatment of adhesive capsulitis. Furthermore, this study will serve as a valuable guideline for practitioners when making clinical decisions and managing adhesive capsulitis.

Comparative Effectiveness of Corticosteroid Dosages for Ultrasound-Guided Glenohumeral Joint Hydrodilatation in Adhesive Capsulitis: A Randomized Controlled Trial

OBJECTIVE

To investigate the efficacy of hydrodilatation with 40 mg triamcinolone acetonide (TA) compared with the same procedure with 10 mg TA in patients with adhesive capsulitis (AC) of the shoulders.

DESIGN

Prospective, double-blind, randomized controlled trial with 12 weeks of follow-up.

SETTING

Tertiary care rehabilitation center.

PARTICIPANTS

Eighty-four patients diagnosed with AC (N=84).

INTERVENTIONS

Ultrasound guidance using (A) hydrodilatation with 4 mL of TA (40 mg)+4 mL 2% lidocaine hydrochloride+12 mL normal saline or (B) hydrodilatation with 1 mL of TA (10 mg)+4 mL 2% lidocaine hydrochloride+15 mL normal saline through the posterior glenohumeral recess.

MAIN OUTCOME MEASURES

Shoulder Pain and Disability Index (SPADI), visual analog scale (VAS) for pain, and range of motion (ROM) at baseline and at 6 and 12 weeks after injection.

RESULTS

Both groups experienced improvements in the SPADI score, VAS scores for pain, and ROM throughout the study period. However, group-by-time interactions were not significant for any outcome measurement at any follow-up time point. No adverse events were reported in either group.

CONCLUSION

Ultrasound-guided hydrodilatation with 40 and 10 mg TA yielded similar improvements in SPADI, VAS score, and ROM at the 12-week follow-up. Considering the potential detrimental effects of corticosteroids on the adjacent cartilage and tendons, a low dose of TA would be preferable for ultrasound-guided hydrodilatation for AC.

Squishing sound heard following an intra-articular shoulder injection with fluid and air is associated with higher efficacy: A retrospective analysis

BACKGROUND

Accuracy of blind intra-articular injections for the shoulder is rather low. It is unclear whether accurate injections for capsulitis of the shoulder are more effective than inaccurate injections.

OBJECTIVE

It has been hypothesized that a squishing sound following an intra-articular injection with a mixture of air and fluid means that the injection was accurately placed and that the efficacy of accurately placed injections is greater than that of inaccurate injections. The aim of the present study was to test the hypothesis that a squishing sound following an injection predicts a better clinical result.

METHODS

Files were selected of patients with capsulitis of the shoulder, who were treated with an intra-articular injection containing a mixture of triamcinolone, lidocaine, and air. After the injection, the shoulder was moved to determine whether a squishing sound could be produced. Efficacy was measured after two weeks according to the Patient Global Impression of Change scale. Differences in efficacy between injections with and without a squishing sound were expressed as an odds ratio.

RESULTS

Sixty-one patients were selected. Squishing was heard after 47 injections (77%). Two weeks after the injection, a positive outcome was reported by 49 patients (80%). When squishing was heard, the effect was positive in 42 of the 47 patients (89%) and when no squishing was heard, the effect was positive in 7 of the 14 patients (50%). The odds ratio was 8.4 (95% CI 2.1-34.0; p= 0.003).

CONCLUSION

Efficacy of injections with a mixture of triamcinolone, lidocaine, and air for capsulitis of the shoulder is significantly greater when a squishing sound was heard after the injection. We hypothesize that squishing is related to accuracy and accuracy to efficacy. A future study with X-ray arthrography is needed to verify both hypotheses.

The role of suprascapular nerve block in hydrodilatation for frozen shoulder

Introduction: Frozen shoulder is a debilitating problem that requires comprehensive diagnosis and management. Patients usually recover, but the possibility of not reobtaining a full range of motion exists. Thus, early shoulder exercises are necessary to achieve their full range of motion. This study aims to understand the effects of suprascapular nerve block (SSNB) augmentation at the spinoglenoid notch in hydrodilatation to treat frozen shoulder to facilitate early shoulder exercises. Methods: The current study retrospectively observed 31 patients, including 40–60-year-old patients diagnosed and treated with primary frozen shoulder. The participants were divided into groups A (hydrodilatation) and B (hydrodilatation and the augmentation of an SSNB). Shoulder function and pain scores were assessed before, during, and after the intervention (at months 1 and 6). Results: The result of this study shows that suprascapular nerve block plays a role in decreasing pain in intraintervention (0.69 vs. 5.73; p < 0.05), month 1 of follow-up (3.44 vs. 6.40; p < 0.05), but not significant on month 6 of group A and B after intervention (5.88 vs. 7.20; p > 0.05). Better delta functional scores were noted in the therapy group during month 1 of the follow-up (delta American shoulder and elbow surgeons [ASES]: 19.29 vs. 34.40, p < 0.05; delta disabilities of the arm, shoulder, and hand [DASH]: 17.88 vs. 38.15, p < 0.05). The difference in functional score on month 6 between both groups was not significantly different (delta ASES: 31.97 vs. 30.31, p > 0.05; delta DASH: 36.63 vs. 38.92, p > 0.05). Discussion: One rationale for using an SSNB augmentation at spinoglenoid notch in hydrodilatation for treating frozen shoulder was to obtain pain relief immediately to facilitate early manual exercise. SSNB has positive effects on short-term evaluation of shoulder pain and function after glenohumeral hydrodilatation, but not in the long term.

Functional improvement of bilateral frozen shoulder by unilateral intra-articular corticosteroid injection: a retrospective study

Objective

Bilateral frozen shoulder (FS) is often treated with intra-articular corticosteroid injection (IACI). No studies have been performed to establish whether IACI must be administered in both shoulders or in only one shoulder to improve function. This study was therefore performed to determine whether unilateral IACI improves shoulder pain and passive range of motion (pROM) in bilateral FS.

Methods

The medical records of 165 patients with bilateral primary FS who underwent ultrasonography-guided IACI (2 mL of 10-mg/mL triamcinolone acetonide mixed with 5 mL of 1% lidocaine) in one shoulder were retrospectively reviewed. The outcome measures, namely the numeric rating scale (NRS) scores and pROM values (abduction, external rotation, flexion, hyperextension, and internal rotation), were evaluated pre- and post-injection.

Results

The patients’ mean age was 54.0 ± 8.0 years. The mean symptom duration was 6.5 ± 2.8 months. The mean follow-up period after injection was 6.7 ± 0.8 weeks. The NRS scores and pROM values significantly improved in both the injected and non-injected shoulders.

Conclusions

This study showed that unilateral IACI in patients with bilateral FS improves the clinical outcome of the non-injected shoulder. We suggest that physicians observe the non-injected shoulder after unilateral injection rather than performing bilateral injections.

Updates on the treatment of adhesive capsulitis with hydraulic distension

Adhesive capsulitis of the shoulder joint is a common disease characterized by pain at the insertional area of the deltoid muscle and decreased range of motion. The pathophysiological process involves fibrous inflammation of the capsule and intraarticular adhesion of synovial folds leading to capsular thickening and contracture. Regarding the multidirectional limitation of motion, a limitation in external rotation is especially prominent, which is related to not only global fibrosis but also to a localized tightness of the anterior capsule. Ultrasound and magnetic resonance imaging studies can be applied to rule out other structural lesions in the diagnosis of adhesive capsulitis. Hydraulic distension of the shoulder joint capsule provides pain relief and an immediate improvement in range of motion by directly expanding the capsule along with the infusion of steroids. However, the optimal technique for hydraulic distension is still a matter of controversy, with regards to the infusion volume and rupture of the capsule. By monitoring the real-time pressure-volume profile during hydraulic distension, the largest possible fluid volume can be infused without rupturing the capsule. The improvement in clinical outcomes is shown to be greater in capsule-preserved hydraulic distension than in capsule-ruptured distension. Moreover, repeated distension is possible, which provides additional clinical improvement. Capsule-preserved hydraulic distension with maximal volume is suggested to be an efficacious treatment option for persistent adhesive capsulitis.

Pharmacodynamics, efficacy, safety and administration of intra-articular therapies for knee osteoarthritis

Introduction: Osteoarthritis (OA) is the leading cause of disability in the elderly, usually presenting with mono-or oligo-arthritis where local drug delivery by intra-articular (IA) injection may be more effective in terms of increased bioavailability, less systemic exposure and reduced adverse events. Several intra-articular medications for symptomatic are available on the market while the new disease-modifying drugs (DMOADs) are progressing into phase 3 pipeline of drug development.Areas covered: This narrative review covered the pharmacokinetic and pharmacodynamics of clinically available IA drugs which include corticosteroids, hyaluronic acid as well as injection techniques, efficacy, adverse effects and contraindications. In addition, the authors briefly describe the newer disease-modifying OA drugs (DMOAD) which are undergoing phase 3 pipeline of development such as Fibroblast growth factor (FGF-18) and Wnt inhibitor.Expert opinion: This is a rapidly evolving area with both new products and new trials regularly emerging. It is also a critically important area in a disease field that lacks for safe and effective treatments, where intra-articular delivery may enhance both local efficacy and reduce systemic toxicity.

[Conservative treatment of frozen shoulder]

Idiopathic shoulder stiffness (i.e. frozen shoulder, FS) is a common pathology of the glenohumeral joint characterized by a sudden onset of pain syndrome and progressive restriction of the range of motion. While the histological changes of FS are accompanied by synovial inflammation and increasing capsular fibrosis, the underlying cause of FS is still unknown. The treatment options for FS are multifarious and include medication, local steroid injection, physiotherapy, hydrodistension, manipulation under anesthesia, arthroscopic and open capsular release. As the disease is usually self-limiting and the symptoms resolve after 2-3 years, especially conservative treatment measures are often clinically applied; however, in this context there is still no scientifically based consensus on which treatment measures are most likely to contribute to symptom relief in which phase of the disease. For this reason, this article focuses on the description of the scientifically investigated conservative treatment methods in FS and their temporal classification into the classical three-phase course of the disease.

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.

Ultrasound-Guided Standard vs Dual-Target Subacromial Corticosteroid Injections for Shoulder Impingement Syndrome: A Randomized Controlled Trial

OBJECTIVE

To compare dual-target injection with standard ultrasound (US)-guided subacromial injection in patients with subacromial impingement syndrome (SIS) and possible disorders of the biceps long-head tendons.

DESIGN

Double-blind, randomized controlled trial.

SETTING

Rehabilitation outpatient clinic.

PARTICIPANTS

Patients with SIS (N=60).

INTERVENTION

(1) US-guided standard subacromial bursa; (2) dual-target (subacromial bursa plus proximal biceps long-head tendon) injection, with 40-mg triamcinolone acetonide administered to patients in each group.

MAIN OUTCOME MEASURES

Clinical assessments were performed at baseline. The outcomes, including results from a self-administered questionnaire, the Shoulder Pain and Disability Index (SPADI), and a self-pain report, the visual analog scale (VAS) scores for pain at rest, at night, and during overhead activities, were evaluated at baseline and at the first and third months postintervention.

RESULTS

No significant difference was observed in baseline evaluations between groups (n=30 in each treatment arm) prior to injections. Both groups exhibited significant SPADI and VAS-score improvements after the first month. The dual-target injection group had less rebounding pain at the 3-month follow-up. The standard injection group had more patients reporting worsening pain within 1 day postinjection.

CONCLUSION

US-guided dual-target corticosteroid injection showed similar short-term efficacy to standard subacromial injections, but with an extended duration of symptom relief. Therefore, dual-target corticosteroid injections may be useful for shoulder pain treatment in patients with SIS.

High- vs Low-Dose Corticosteroid Injection in the Treatment of Adhesive Capsulitis with Severe Pain: A Randomized Controlled Double-Blind Study

Objective

To compare the degree of pain relief between high-dose (40 mg of triamcinolone acetonide) and low-dose (20 mg of triamcinolone acetonide) corticosteroid injections in patients with severe pain due to adhesive capsulitis.

Design

A prospective, randomized, double-blind, dose-comparative study.

Subjects

A total of 32 patients who were diagnosed with adhesive capsulitis and who expressed severe pain intensity, 8 or more points on a numeric rating scale (NRS).

Methods

Patients received injections of high- or low-dose triamcinolone acetonide under ultrasound guidance. NRS, Shoulder Pain and Disability Index (SPADI), and the passive range of motion (PROM) in four directions were evaluated before and three weeks after the injection.

Results

NRS scores showed significant improvement three weeks after the injection in both groups (P = 0.01 in both the low-dose group and high-dose group), but there was no statistically significant difference between the two groups (P = 0.63). SPADI score significantly improved at three weeks after the injection in both groups (P = 0.02 in the low-dose group and P < 0.01 in the high-dose group), but group difference was not observed (P = 0.06). The change of PROM in four directions after the injection did not show any significant difference between the low- and high-dose groups.

Conclusions

Injection of 20 mg of triamcinolone acetonide is sufficient to elicit symptom relief in patients with severe adhesive capsulitis; hence, 20 mg of triamcinolone acetonide can be recommended in patients with adhesive capsulitis with severe pain.

The Effect of Corticosteroid Injection Into Rotator Interval for Early Frozen Shoulder: A Randomized Controlled Trial

BACKGROUND

Corticosteroid injection is a common treatment for frozen shoulder, but controversy still exists regarding the injection site with the best outcome.

HYPOTHESIS

To treat the frozen shoulder in the freezing stage with corticosteroid injection, a single injection into the rotator interval (RI) could yield better effects in terms of improvement in pain, passive range of motion (ROM), and function than would an injection into the intra-articular (IA) or subacromial (SA) space.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

Patients with primary frozen shoulder in the freezing stage were randomized into 3 groups: RI injection, IA injection, or SA injection with corticosteroid. Clinical outcomes were documented at baseline and at 4, 8, and 12 weeks after intervention, including visual analog scale (VAS) for pain; passive ROM measurements, including external rotation, internal rotation, forward flexion, and abduction; and evaluation with the Disability of Arm, Hand, and Shoulder (DASH) score and Constant score.

RESULTS

There were no significant differences in the basic properties of the 3 groups (27 in RI group, 24 in IA group, and 26 in SA group) before injection. Improvements in pain VAS, passive ROM, Constant score, and DASH score were faster and significant in the RI group from 4 weeks after injection, followed by those in the IA group. Passive ROM decreased and DASH score did not change significantly in the SA group, although pain VAS and Constant score improved significantly.

CONCLUSION

To treat frozen shoulder in the freezing stage with corticosteroid injection, a single injection into the RI yielded better effects in terms of improvement in pain, passive ROM, and function than did injections into the IA or SA space.

Comparative Efficacy of Intra-Articular Steroid Injection and Distension in Patients With Frozen Shoulder: A Systematic Review and Network Meta-Analysis

OBJECTIVE

To compare the efficacy of intra-articular (IA) steroid injection and distension in patients with frozen shoulder.

DATA SOURCES

Databases, including MEDLINE (via PubMed), Embase, Scopus, and Cochrane Library, were searched for studies published up to November 2016.

STUDY SELECTION

We included all published randomized controlled trials (RCTs), quasi-experimental studies, and observational studies investigating the effectiveness of IA steroid injection, distension, and physiotherapy in patients with frozen shoulder. Sixteen RCTs and 1 observational study were enrolled in meta-analysis.

DATA EXTRACTION

Full texts were independently reviewed, and quality of RCTs was assessed with The Cochrane Collaboration's tool. The primary outcome was functional improvement; the secondary outcomes included pain reduction and external rotation (ER) improvement.

DATA SYNTHESIS

In pairwise meta-analysis, pooled standardized mean difference (SMD) of functional improvement and pain reduction revealed equal efficacy at 3 follow-up time points. With respect to ER improvement, distension has a superior effect compared with IA steroid injection in the short term [(2-4wk; SMD, -.36; 95% confidence interval [CI], -.68 to -.04) and medium term (6-16wk; SMD, -0.80; 95% CI, -1.32 to -0.29). The network meta-analysis indicated a better efficacy for distension than for IA steroid injection in ER improvement only in the medium term (6-16wk; SMD, -0.70; 95% CI, -1.19 to -0.21).

CONCLUSIONS

IA steroid injection was as effective as distension in shoulder function improvement, pain reduction, and increasing ER of the shoulder. Distension yielded better ER improvement in the medium term but to a minor extent in the long term. For patients with predominant ER limitation, early distension could be considered the primary choice of treatment.

Corticosteroid Injections for Adhesive Capsulitis: A Review

OBJECTIVE

Adhesive capsulitis is a self-limiting condition in a majority of patients and is often treated nonoperatively. However, symptoms may take 2 to 3 years to resolve fully. A small, but significant, portion of patients require surgical intervention. The purpose of this systematic review is to evaluate the efficacy of corticosteroid injections for the treatment of adhesive capsulitis (AC).

DATA SOURCES

A review of articles indexed by the United States National Library of Medicine was conducted by querying the PubMed database for studies involving participants with AC, frozen shoulder, stiff shoulder, or painful shoulder. Articles that included corticosteroids, glucocorticoids, steroids, and injections were included.

MAIN RESULTS

Corticosteroid injections provide significant symptom relief for 2 to 24 weeks. Injections can be performed intra-articularly or into the subacromial space. Evidence suggests that a 20 mg dose of triamcinolone may be as effective as a 40 mg injection. It remains unclear whether image-guided injections produce a clinically significant difference in outcomes when compared with landmark-guided (blind) injections. Corticosteroids may be less beneficial for diabetic patients. Patients using protease inhibitors (antiretroviral therapy) should not receive triamcinolone because the drug-drug interaction may result in iatrogenic Cushing syndrome.

CONCLUSIONS

Corticosteroid injections for AC demonstrate short-term efficacy, but may not provide a long-term benefit. More high quality, prospective studies are needed to determine whether corticosteroid injections using ultrasound guidance significantly improve outcomes.

Comparison of high- and low-dose intra-articular triamcinolone acetonide injection for treatment of primary shoulder stiffness: a prospective randomized trial

BACKGROUND

Intra-articular corticosteroid injection has a proven effect for shoulder stiffness, yet the optimal dose is still controversial. The purpose of the study was to compare the outcomes of intra-articular triamcinolone acetonide injection at 2 different doses in patients with shoulder stiffness.

METHODS

Intra-articular injection of 40 mg (group I, n = 76) or 20 mg (group II, n = 71) of triamcinolone acetonide was performed in patients with shoulder stiffness. The outcome measures including range of motion (ROM), American Shoulder and Elbow Surgeons score, visual analog scale for pain score, and Simple Shoulder Test score were evaluated at 3 weeks, 6 weeks, 12 weeks, 6 months, 12 months, and the last follow-up. Among the patients with controlled diabetes, the levels of blood glucose, fructosamine, and HbA_1c were measured to evaluate systemic serologic changes induced by injection.

RESULTS

There were significant improvements in ROM and functional scores in both groups at the last follow-up. However, there was no significant difference between the groups in any of the parameters at each time point. None of the diabetic patients in either group had a significant increase in blood glucose, fructosamine, and HbA_1c levels compared with levels before injection. However, those in group I showed significantly higher blood glucose levels at 6 weeks after injection compared with those in group II (P = .01).

CONCLUSION

Intra-articular injection of triamcinolone is an effective method for improving ROM and clinical function in patients with shoulder stiffness. However, there was no significant difference in regard to different doses. In diabetic patients, a lower dose is recommended as short-term glucose levels may increase with a high dose of corticosteroid.

Thawing frozen shoulder by steroid injection

BACKGROUND

Frozen shoulder is not an uncommon disorder, and steroid injection into the glenohumeral (GH) joint is one of the most well-known approaches for the frozen shoulder. However, their results have been varied with beneficial effects or no additional advantage. With the understanding about the pathological changes taking place in frozen shoulder and the biomechanics involved, we wanted to evaluate the short- and long-term efficacy of steroid injection by a novel three-site (NTS) injection technique and compare it with the single-site injection (SSI).

MATERIAL AND METHODS

This was a prospective study with 85 patients including all stages and randomized into two groups. SSI group received steroid injection through posterior approach. NTS group received the same dose of steroid in diluted doses at three sites (posterior capsule, subacromial and subcoracoid). Second sitting was repeated after 3 weeks. Both groups had received the same physiotherapy. The patients were evaluated by CONSTANT score at initial, 3 week, 6 week and 6 month.

RESULTS

NTS group patients had significant pain relief and early improvement in activities of daily living ( p < 0.005). Both groups had improvement in shoulder movements but with NTS group, early near-normal scores were attained and sustained after 6 months. About 43% in SSI group could not attain near-normal levels and had relapses.

CONCLUSION

The three-site approach to steroid instillation in frozen shoulder is a safe method and provides early recovery and better improvement in shoulder function with less relapses.

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.

Adhesive capsulitis of the shoulder, treatment with corticosteroid, corticosteroid with distension or treatment-as-usual; a randomised controlled trial in primary care

BACKGROUND

Optimal management for adhesive shoulder capsulitis (frozen shoulder) is currently unclear. We intended to explore whether treatment by intra-articular injections with corticosteroid and distension is more effective than treating with corticosteroids alone or treatment-as-usual in a primary care setting in Norway.

METHODS

In this prospective randomised intention to treat parallel study, 106 patients were block randomised to three groups; 36 (analysed 35) receiving steroid injection and Lidocaine (IS), 34 receiving steroid and additional saline as distension (ISD) and 36 had treatment-as-usual (TAU). Intervention groups received four injections within 8 weeks, assessed on 1st visit, at the 4th and 8th week. Outcomes were Shoulder Pain and Disability Index (SPADI), Numerical pain rating scale (NPRS) and passive range of motion (PROM). Postal assessment was repeated after 1 year for SPADI. Patients in the IS and ISD groups were "blinded" for intervention received and the assessor was "blinded" to group allocation.

RESULTS

At baseline there were no differences between groups in outcome measures. There were no statistical significant differences between the intervention groups in SPADI, NPRS and PROM at baseline, at short-term (4-and 8 weeks) or long-term (12 months). There were statistically significant differences (p < 0.01) in change scores at short-term for SPADI when comparing the IS and TAU groups (-20.8; CI-28.9 to -12.7), and the ISD and TAU groups (-21.7; CI-29.4 to -14.0), respectively for NPRS (-2.0; CI-2.8 to -1.1 and -2.2; CI-3.0 to -1.4), and for PROM, but not at long-term for SPADI (p > 0.05). Effect size (ES) at 8 weeks was large between both injection groups and TAU (ES 1.2). At 12 months ES was reduced to 0.3 and 0.4 respectively. Transitory side effects as flushing and after-pain were reported by 14 % in intervention groups.

CONCLUSION

This intention to treat RCT in primary care indicates that four injections with corticosteroid with or without distension, given with increasing intervals during 8 weeks, were better than treatment-as-usual in treatment of adhesive shoulder capsulitis. However, in the long run no difference was found between any of the groups, indicating that natural healing takes place independent of treatment or not.

TRIAL REGISTRATION

ClinicalTrials.gov, https://clinicaltrials.gov/ identifier: NCT01570985.

Steroid Injection Versus Physiotherapy for Patients With Adhesive Capsulitis of the Shoulder: A PRIMSA Systematic Review and Meta-Analysis of Randomized Controlled Trials

To compare the effect of steroid injection and physiotherapy for patients with adhesive capsulitis of the shoulder (ACS).An electronic search was performed on Pubmed, Embase, and Cochrane library, and reference lists were also reviewed for randomized controlled trials (RCTs) comparing steroid injection and physiotherapy for patients with ACS. The quality of included studies were assessed using PEDro scale. Standardized mean differences (SMDs) and 95% confidence interval (CI) were used for comparisons. The primary outcome was functional improvement.Nine RCTs including 453 patients were identified. From 6-7 weeks to 24-26 weeks postintervention, no superiority was noted in favor of either steroid injection or physiotherapy for functional improvement (SMD 0.28; 95% CI -0.01-0.58; P = 0.06) or pain relief (SMD -0.10; 95% CI -0.70-0.50; P = 0.75). Steroid injection provided more improvement in passive external rotation at 24 to 26 weeks (3 studies, SMD 0.42; 95% CI 0.11-0.72; P = 0.007) but not at 6 to 7 weeks (4 studies, SMD 0.63; 95% CI 0.36-0.89; P = 0.32) or 12 to 16 weeks (3 studies, SMD -0.07; 95% CI -0.79-0.65; P = 0.85). Steroid injection was as safe as physiotherapy for patients with ACS (risk ratio 0.94; 95% CI 0.67-1.31).Both steroid injection and physiotherapy are equally effective for patients with ACS. One steroid injection might be the 1st choice for ACS. Results should be interpreted with caution due to the heterogeneity among the studies.

Prognostic factors and therapeutic options for treatment of frozen shoulder: a systematic review

PURPOSE

To evaluate the current status of scientific research on the natural history of frozen shoulder as published in the literature.

MATERIALS AND METHODS

This systematic review was carried out on PubMed data and was guided by PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). Articles had to meet inclusion criteria. The quality of the papers was assessed using a newly developed tool, AMQPP (Assessing the Methodological Quality of Published Papers). The AMQPP score was correlated with the level of evidence rating according to the Oxford Centre for Evidence-Based Medicine. Suitable papers were divided into groups according to the shoulder condition on which they reported. This article focuses on the frozen shoulder.

RESULTS

Seven articles on frozen shoulder met the inclusion criteria. One article was considered to have level 1 of evidence. Three articles had level 3 and the remaining 3 had level 4. Three papers assessed the natural history and the natural course of different forms of stiff shoulder. The others indirectly assessed the natural history by evaluating therapy trends. None of the articles clearly referred to the role of regression to the mean of frozen shoulder specifically.

CONCLUSION

Spontaneous recovery to normal levels of function is possible and standardised non-operative treatment programmes are an effective alternative to surgery in most cases. However, patients with high risk factors such as diabetes mellitus, and those who suffer chronic symptoms or bilaterally affected, would benefit from early surgery. We also concluded that AMQPP score is simple and straight forward. It works as a quick quality-checking tool which helps researchers to identify the key points in each paper and reach a decision regarding the eligibility of the paper more easily. The AMQPP score is still open for further development.

Steroid Injection and Nonsteroidal Anti-inflammatory Agents for Shoulder Pain: A PRISMA Systematic Review and Meta-Analysis of Randomized Controlled Trials

Advantages and possible risks associated with steroid injection compared with nonsteroidal anti-inflammatory drugs (NSAIDs) for shoulder pain are not fully understood. To compare the efficiency and safety of steroid injection versus NSAIDs for patients with shoulder pain. PubMed, Embase, and the Cochrane Library were searched through July 2015. Study eligibility criteria, participants, and interventions: randomized controlled trials (RCTs) that assessed steroid injection versus NSAIDs for patients with shoulder pain. Study appraisal and synthesis methods: predefined primary efficacy outcome was functional improvement; and secondary efficacy outcomes included pain relief and complications. Relative risks (RRs) and standardized mean differences (SMDs) with 95% confidence intervals (CIs) were calculated using a random-effects model accounting for clinical heterogeneity. Eight RCTs involving 465 participants were included in the meta-analysis. Five trials compared steroid injection with oral NSAIDs, and 3 compared steroids injection with NSAIDs injection. Compared with steroid injection, oral NSAIDs were less effective in 4 or 6 weeks for functional improvement (SMD 0.61; 95% CI, 0.08-1.14; P = 0.01), while there was no significant difference in pain relief (SMD 0.45; 95% CI, -0.50-1.40; P < 0.00001) or complication rate (RR 1.10; 95% CI, 0.26-4.58; P = 0.29). Meta-analysis was not performed for NSAIDs injection due to considerable heterogeneity. Conflicting results were observed in favor of either steroid or NSAIDs injection. Not all diseases that can lead to shoulder pain were included, detailed intervention protocols were inconsistent across studies, and some estimated data were input into comparison while some data were lost, which could exert an influence on pooled results. Steroid injection, compared with oral NSAIDs, provides slightly more improvement in shoulder function without superiority in pain relief or risk of complications at 4 to 6 weeks. Treatment decision should be made based on diseases. NSAIDs injection might be a treatment method for shoulder pain.

What's changed in the management of the frozen shoulder?

Frozen shoulder is a painful condition in which movement of the shoulder becomes restricted. It can interfere with domestic and social activities and affect the ability to work. The condition can vary from mild to severe in terms of pain and/or restricted movement. We last reviewed the management of frozen shoulder 15 years ago. We concluded then that there was no clear evidence that any treatment could shorten the natural history of the condition and found little evidence as to the best management option. Here, we review the evidence on treatment approaches published in the meantime.

Glenohumeral corticosteroid injections in adhesive capsulitis: a systematic search and review

OBJECTIVE

To assess the literature on outcomes of corticosteroid injections for adhesive capsulitis, and, in particular, image-guided corticosteroid injections. TYPE: Systematic search and review.

LITERATURE SURVEY

The databases used were PubMed (1966-present), EMBASE (1947-present), Web of Science (1900-present), and the Cochrane Central Register of Controlled Trials. Upon reviewing full-text articles of these studies, a total of 25 studies were identified for inclusion. The final yield included 7 prospective studies, 16 randomized trials, and 2 retrospective studies.

METHODOLOGY

This systematic review was formatted by using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Study criteria were limited to clinical trials, prospective studies, and retrospective studies that specifically evaluated intra-articular corticosteroid injections, both alone and in combination with other treatment modalities, for shoulder adhesive capsulitis. We included studies that were not randomized control trials because our review was not a meta-analysis. Data items extracted from each study included the following: study design, study population, mean patient age, duration of study, duration of symptoms, intervention, single or multiple injections, location of injections, control population, follow-up duration, and outcome measurements. A percentage change in outcome measurements was calculated when corresponding data were available. Risk of bias in individual studies was assessed when appropriate.

SYNTHESIS

All the studies involved at least 1 corticosteroid injection intended for placement in the glenohumeral joint, but only 8 studies used image guidance for all injections. Seven of these studies reported statistically significant improvements in range of motion at or before 12 weeks of follow-up. Ninety-two percent of all the studies documented a greater improvement in either visual analog pain scores or range of motion after corticosteroid injections in the first 1-6 weeks compared with the control or comparison group.

CONCLUSIONS

Corticosteroid injections offer rapid pain relief in the short-term (particularly in the first 6 weeks) for adhesive capsulitis. Long-term outcomes seem to be similar to other treatments, including placebo. The added benefit of image-guided corticosteroid injections in improving shoulder outcomes needs further assessment.

Glenohumeral joint injections: a review

Context:

Intra-articular injections into the glenohumeral joint are commonly performed by musculoskeletal providers, including orthopaedic surgeons, family medicine physicians, rheumatologists, and physician assistants. Despite their frequent use, there is little guidance for injectable treatments to the glenohumeral joint for conditions such as osteoarthritis, adhesive capsulitis, and rheumatoid arthritis.

Evidence Acquisition:

We performed a comprehensive review of the available literature on glenohumeral injections to help clarify the current evidence-based practice and identify deficits in our understanding. We searched MEDLINE (1948 to December 2011 [week 1]) and EMBASE (1980 to 2011 [week 49]) using various permutations of intra-articular injections AND (corticosteroid OR hyaluronic acid) and (adhesive capsulitis OR arthritis).

Results:

We identified 1 and 7 studies that investigated intra-articular corticosteroid injections for the treatment of osteoarthritis and adhesive capsulitis, respectively. Two and 3 studies investigated the use of hyaluronic acid in osteoarthritis and adhesive capsulitis, respectively. One study compared corticosteroids and hyaluronic acid injections in the treatment of osteoarthritis, and another discussed adhesive capsulitis.

Conclusion:

Based on existing studies and their level of evidence, there is only expert opinion to guide corticosteroid injection for osteoarthritis as well as hyaluronic acid injection for osteoarthritis and adhesive capsulitis.

Optimal dose of intra-articular corticosteroids for adhesive capsulitis: a randomized, triple-blind, placebo-controlled trial

BACKGROUND

Intra-articular corticosteroid injection is a commonly used therapy for adhesive capsulitis, but there are only few studies that compare the efficacy of corticosteroids according to different doses.

PURPOSE

To determine whether intra-articular injections with a high-dose corticosteroid improves pain and function in patients with adhesive capsulitis better than a low dose or a placebo.

STUDY DESIGN

Randomized controlled clinical trial; Level of evidence, 1.

METHODS

Participants (n = 53) with primary adhesive capsulitis in the freezing stage were randomly assigned to receive ultrasound-guided intra-articular injections with 40 mg triamcinolone acetonide (high-dose group, n = 20), 20 mg triamcinolone acetonide (low-dose group, n = 20), or placebo (n = 13). After a single injection, participants were all instructed to carry out a home exercise program. The outcome measures included the Shoulder Pain and Disability Index (SPADI), visual analog scale (VAS) for average shoulder pain level, and passive range of motion including flexion, abduction, extension, external rotation, and internal rotation before treatment and at weeks 1, 3, 6, and 12 after treatment.

RESULTS

There were no significant differences in demographic and clinical characteristics at baseline between the 3 groups. Repeated-measures analysis of variance and post hoc tests showed improvement in SPADI and VAS scores and in flexion, abduction, and internal rotation especially for the low- and high-dose groups compared with the placebo. Yet, no significant difference was found between the 2 different corticosteroid dose groups.

CONCLUSION

We assessed the efficacy of corticosteroid injections according to 2 different doses that are most widely used in intra-articular injections for adhesive capsulitis. This study shows that there were no significant differences between the high- and low-dose corticosteroid groups, indicating the preferred use of a low dose in the initial stage.

A randomized controlled trial evaluating the cost-effectiveness of sonographic guidance for intra-articular injection of the osteoarthritic knee

OBJECTIVE

The present randomized controlled study investigated whether sonographic needle guidance affected the outcomes of intra-articular injection for osteoarthritis of the knee.

METHODS

Ninety-four noneffusive knees with osteoarthritis were randomized to injection by conventional palpation-guided anatomic landmark injection or sonographic image-guided injection enhanced with a 1-handed mechanical (the reciprocating procedure device) syringe. After intra-articular placement and synovial space dilation were confirmed by sonography, a syringe exchange was performed, and 80 mg of triamcinolone acetonide was injected with the second syringe through the indwelling intra-articular needle. Baseline pain, procedural pain, pain at outcome (2 weeks and 6 months), responders, therapeutic duration, reinjection rates, total cost, and cost per responder were determined.

RESULTS

Relative to conventional palpation-guided anatomic landmark methods, sonographic guidance for injection of the knee resulted in 48% reduction in procedural pain (P < 0.001), a 42% reduction in pain scores at outcome (P < 0.03), 107% increase in the responder rate (P < 0.001), 52% reduction in the nonresponder rate (P < 0.001), a 36% increase in therapeutic duration (P = 0.01), a 13% reduction ($17) in cost per patient per year, and a 58% ($224) reduction in cost per responder per year for a hospital outpatient (P < 0.001).

CONCLUSIONS

Sonographic needle guidance reduced procedural pain and improved the clinical outcomes and cost-effectiveness of intra-articular injections of the osteoarthritic knee.

Comparison of Sono-guided Capsular Distension with Fluoroscopically Capsular Distension in Adhesive Capsulitis of Shoulder

Objective

To investigate the short-term effects and advantages of sono-guided capsular distension, compared with fluoroscopically guided capsular distension in adhesive capsulitis of shoulder.

Method

In this prospective, randomized, and controlled trial, 23 patients (group A) were given an intra-articular injection of a mixture of 0.5% lidocaine (9 ml), contrast dye (10 ml), and triamcinolone (20 mg); they received the injection once every 2 weeks, for a total of 6 weeks, under sono-guidance. Twenty-five patients (group B) were treated similarly, under fluoroscopic guidance. Instructions for the self-exercise program were given to all subjects, without physiotherapy and medication. Effects were then assessed using a visual numeric scale (VNS), and the shoulder pain and disability index (SPADI), as well as a range of shoulder motion examinations which took place at the beginning of the study and 2 and 6 weeks after the last injection. Incremental cost-effective ratio (ICER), effectiveness, preference, and procedure duration were evaluated 6 weeks post-injection.

Results

The VNS, SPADI, and shoulder motion range improved 2 weeks after the last injection and continued to improve until 6 weeks, in both groups. However, no statistical differences in changes of VNS, SPADI, ROM, and effectiveness were found between these groups. Patients preferred sono-guided capsular distension to fluoroscopically guided capsular distension due to differences in radiation hazards and positional convenience. Procedure time was shorter for sono-guided capsular distension than for fluoroscopically guided capsular distension.

Conclusion

Sono-guided capsular distension has comparable effects with fluoroscopically guided capsular distension for treatment of adhesive capsulitis of the shoulder. Sono-guided capsular distension can be substituted for fluoroscopic capsular distension and can be advantageous from the viewpoint of radiation hazard mitigation, time, cost-effectiveness and convenience.

Does ultrasound guidance improve the outcomes of arthrocentesis and corticosteroid injection of the knee?

OBJECTIVE

The present randomized controlled trial compared arthrocentesis of the effusive knee followed by corticosteroid injection performed by the conventional anatomic landmark palpation-guided technique to the same procedure performed with ultrasound (US) needle guidance.

METHODS

Sixty-four palpably effusive knees were randomized to (i) palpation-guided arthrocentesis with a conventional 20-mL syringe (22 knees), (ii) US-guided arthrocentesis with a 25-mL reciprocating procedure device (RPD) mechanical aspirating syringe (22 knees), or (iii) US-guided arthrocentesis with a 60-mL automatic aspirating syringe (20 knees). The one-needle two-syringe technique was used. Outcome measures included patient pain by the Visual Analogue Scale (VAS) for pain (0-10 cm), the proportion of diagnostic samples, synovial fluid volume yield, complications, and therapeutic outcome at 2 weeks.

RESULTS

Sonographic guidance resulted in 48% less procedural pan (VAS; palpation-guided: 5.8 ± 3.0 cm, US-guided: 3.0 ± 2.8 cm, p < 0.001), 183% increased aspirated synovial fluid volumes (palpation-guided: 12 ± 10 mL, US-guided: 34 ± 25 mL, p < 0.0001), and improved outcomes at 2 weeks (VAS; palpation-guided: 2.8 ± 2.4 cm, US-guided: 1.5 ± 1.9 cm, p = 0.034). Outcomes of sonographic guidance with the mechanical syringe and automatic syringe were comparable in all outcome measures.

CONCLUSIONS

US-guided arthrocentesis and injection of the knee are superior to anatomic landmark palpation-guided arthrocentesis, resulting in significantly less procedural pain, improved arthrocentesis success, greater synovial fluid yield, more complete joint decompression, and improved clinical outcomes.

Sample size calculation in physical medicine and rehabilitation: a systematic review of reporting, characteristics, and results in randomized controlled trials

OBJECTIVE

To assess systematically the reporting of sample size calculation in randomized controlled trials (RCTs) in 5 leading journals in the field of physical medicine and rehabilitation (PM&R).

DATA SOURCES

The data source was full reports of RCTs in 5 leading PM&R journals (Journal of Rehabilitation Medicine, Archives of Physical Medicine and Rehabilitation, American Journal of Physical Medicine and Rehabilitation, Clinical Rehabilitation, and Disability and Rehabilitation) between January and December of 1998 and 2008. Articles were identified in Medline.

STUDY SELECTION

A total of 111 articles met our inclusion criteria, which include RCTs of human studies in the 5 selected journals.

DATA EXTRACTION

Sample size calculation reporting and trial characteristics were collected for each trial by independent investigators.

DATA SYNTHESIS

In 2008, 57.3% of articles reported sample size calculation as compared with only 3.4% in 1998. The parameters that were commonly used were a power of 80% and alpha of 5%. Articles often failed to report effect size or effect estimates for sample size calculation. Studies reporting sample size calculation were more likely to describe the main outcome and to have a sample size greater than 50 subjects. The study outcome (positive vs negative) was not associated with the likelihood of sample size reporting. Trial characteristics of the 2 periods (1998 vs 2008) were similar except that in 1998 there were more negative studies compared with 2008.

CONCLUSIONS

Although sample size calculation reporting has improved dramatically in 10 years and is comparable with other fields in medicine, it is still not adequate given current publication guidelines.

The effectiveness of interventions in the management of patients with primary frozen shoulder

There are many types of treatment used to manage the frozen shoulder, but there is no consensus on how best to manage patients with this painful and debilitating condition. We conducted a review of the evidence of the effectiveness of interventions used to manage primary frozen shoulder using the Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects, the Physiotherapy Evidence Database, MEDLINE and EMBASE without language or date restrictions up to April 2009. Two authors independently applied selection criteria and assessed the quality of systematic reviews using the Assessment of Multiple Systematic Reviews (AMSTAR) tool. Data were synthesised narratively, with emphasis placed on assessing the quality of evidence. In total, 758 titles and abstracts were identified and screened, which resulted in the inclusion of 11 systematic reviews. Although these met most of the AMSTAR quality criteria, there was insufficient evidence to draw firm conclusions about the effectiveness of treatments commonly used to manage a frozen shoulder. This was mostly due to poor methodological quality and small sample size in primary studies included in the reviews. We found no reviews evaluating surgical interventions. More rigorous randomised trials are needed to evaluate the treatments used for frozen shoulder.

Good results after fluoroscopic-guided intra-articular injections in the treatment of adhesive capsulitis of the shoulder

The purpose of the present study was the prospective evaluation of the results of fluoroscopic-guided intra-articular cortisone injection series in the treatment of adhesive capsulitis of the shoulder. Twenty-five patients (9 m, 16 w) with a mean age of 49 ± 8 years and stage II frozen shoulder syndrome according to the Reeves classification were treated with an intra-articular cortisone injection series (3 injections at 0, 4, 12, weeks). Clinical examination, ASES score and SF 36 score were performed at 0, 4, 8, 12 weeks, 6 and 12 months. In the results, significant improvements were seen in flexion (99 ± 30°-119 ± 31°, P < .0001), abduction (72 ± 24-99 ± 34°, P < .0001), external rotation (14 ± 16°-28 ± 21°, P < .0001) and internal rotation already at first follow-up after 4 weeks of treatment. The results were confirmed at any other follow-up. ASES score improved from 28 ± 13 to 45 ± 18 after 4 weeks (P < .0001), 59 ± 21 after 8 weeks (P < .0001), 63 ± 25 at 3 months (P < .0001), 64 ± 28 (P < .0001) at 6 months and 73 ± 27 (P < .0001) points at final follow-up after 1 year. Evaluation of the SF-36 Score showed significant improvements in almost all categories (physical and mental) after 4 weeks of treatment (P < .05). In conclusion, a fluoroscopic-guided intra-articular injection series of cortisone is an effective treatment option in frozen shoulder syndrome leading to a fast pain reduction and increased range motion.

Nonoperative management of adhesive capsulitis of the shoulder: oral cortisone application versus intra-articular cortisone injections

HYPOTHESIS

Oral and intra-articular injections of cortisone will lead to significant improvement and comparable results in the treatment of adhesive capsulitis of the shoulder.

MATERIALS AND METHODS

In a prospective randomized evaluation, 40 patients with idiopathic adhesive capsulitis of the shoulder were treated with an oral corticoid treatment regimen or 3 intra-articular injections of corticosteroids. Follow-up was after 4, 8, and 12 weeks, and 6 and 12 months. For the clinical evaluation, the Constant-Murley (CM) score, the Simple Shoulder Test (SST) and visual analog scales (VAS) for pain, function, and satisfaction were used.

RESULTS

In the patients treated with oral glucocorticoids, significant improvements were found for the CM score (P < .0001), SST (P=.035), VAS (P < .0001), and range of motion (P < .05) at the 4-week follow-up. The patients treated with an intra-articular glucocorticoid injection series also significantly improved in the CM score (P < .0001), SST (P < .0001), the VAS (P < .0001), and range of motion (P < .05) after 4 weeks. These results were confirmed at all other follow-up visits. Superior results were found for intra-articular injections in range of motion, CM score, SST, and patient satisfaction (P < .05). Differences in the VAS for pain and function were not significant (P > .05).

DISCUSSION

The use of cortisone in the treatment of idiopathic shoulder adhesive capsulitis leads to fast pain relief and improves range of motion. Intra-articular injections of glucocorticoids showed superior results in objective shoulder scores, range of motion, and patient satisfaction compared with a short course of oral corticosteroids.

Intra-articular corticosteroid injection for the treatment of idiopathic adhesive capsulitis of the shoulder

Treatment for idiopathic adhesive capsulitis or frozen shoulder of the shoulder is controversial. The hypothesis of the study is that intra-articular corticosteroid injection in the early stages of idiopathic adhesive capsulitis will lead to a rapid resolution of stiffness and symptoms. This is a retrospective cohort study of only patients with stage 1 or stage 2 adhesive capsulitis. The diagnosis was made by history and physical examination and only when other causes of pain and motion loss were eliminated. Stage 1 adhesive capsulitis was defined as significant improvement in pain and normalization of motion following intra-articular injection. Stage 2 included patients who had significant improvement in pain and partial improvement in motion following injection. Seven patients with stage 1 and 53 patients with stage 2 comprised the baseline cohort. The mean age was 52 years (range: 30 to 78); 46 patients were female and nine patients had diabetes mellitus. Patients completed a physical examination as well as a shoulder rating questionnaire for symptoms and disability. Criteria for resolution were defined as forward flexion and external rotation to within 15 degrees of the contralateral side and internal rotation to within three spinal levels of the contralateral side. Forty-four of the patients out of 60 met the criteria for recovery at a mean of 6.7 months. The mode and median time to recovery was 3 months. The mean score at final follow-up for 41 patients using the shoulder-rating questionnaire of L'Insalata was 90 (range 52-100). The mean time to recovery for the stage 1 patients was 6 weeks (range: 2 weeks to 3 months), and it was 7 months for stage 2 patients (range: 2 weeks to 2 years). Glenohumeral corticosteroid injection for early adhesive capsulitis may have allowed patients to recover motion at a median time of 3 months. In many cases, the patients had improvement prior to the 3-month mark; however, that was the routine time for follow-up. Patients with stage 1 disease tended to resolve more rapidly than stage 2 patients. Prompt recognition of stage 1 and stage 2 idiopathic adhesive capsulitis and early injection of corticosteroid with local anesthesia may be both diagnostic and therapeutic.