A controlled trial of the benefits of ultrasound-guided steroid injection for shoulder pain

doi:10.1016/j.jbspin.2011.04.001

Joint Bone Spine

Volume 79, Issue 2, March 2012, Pages 166-169

https://doi.org/10.1016/j.jbspin.2011.04.001 Get rights and content

Abstract

Objectives

We studied the value of ultrasound (US) to define shoulder pathology and guide local steroid injection in comparison with a standard injection in the management of the acute painful shoulder.

Methods

Seventy consecutive patients with acute shoulder pain were assessed clinically and by US. Patients were randomized to receive either a standard subacromial infiltration of 7 mg of betamethasone or a US-guided injection according to the US diagnosis. Follow-up evaluations were performed by an independent assessor who was blinded to the results of the initial US and clinical assessments.

Results

Sixty-seven patients completed the study. Both groups showed a significant reduction in both daytime and night pain compared to baseline. The US injection group had significantly less pain at rest at 2 and 6 weeks (NRS: 1.6 vs 3.3, P < 0.005; 3 vs 4.2, P < 0.04). The percentage of good responders was significantly higher in US group at 2 weeks, (81% vs 54%, P < 0.005) and 6 weeks (64% vs 38%, P < 0.05). At 2 and 6 weeks, responder rate and activity pain scores as well as Constant score were in favour of US, though did not reach statistical significance.

Conclusion

Local steroid injection for shoulder pain leads to significant improvements in pain and function for up to 12 weeks. An US examination to define the origin of shoulder pain as well as to guide injection provides significant additional benefits for up to 6 weeks. We recommend routine US examination as part of the management of acute shoulder pain.

Section snippets

Patients

Patients are recruited from three Swiss rheumatology centres between December 2008 and May 2010. Inclusion criteria are patients over age of 18 with shoulder pain that did not respond to NSAID or physiotherapy. Exclusion criteria included history of inflammatory arthritis, radiological gleno-humeral osteoarthritis and previous steroid local injection within 12 weeks. Patients signed an informed consent and were assigned treatment groups by random-number sequence. All patients underwent shoulder

Results

The selection of patients for this study is shown in Fig. 1. Only half of the 143 patients who underwent an initial evaluation could be randomized. Of the 70 randomized patients, 67 completed the study. Two patients did not respond to the two weeks phone call and the next follow-up evaluations, one received a second steroid local injection within the 2 first weeks. Baseline demographics are summarized in Table 1. The two groups were similar with respect to sex, age, pain duration, the number of

Discussion

Our study confirms that local corticosteroid injection produces a significant reduction in shoulder pain in the short term (up to 2 weeks) in all patients, and in addition, US-guided injection to the site of shoulder pathology gave a better result than injection into the subacromial bursa in a blinded fashion. This finding was particular relevant in the reduction of night time shoulder pain at week 2 and week 6, as this most likely has an inflammatory component, and the identification of the

Disclosure of interest

The authors declare that they have no conflicts of interest concerning this article.

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Cited by (40)

Current evidence and practical knowledge for ultrasound-guided procedures in rheumatology: Joint aspiration, injection, and other applications
2023, Best Practice and Research: Clinical Rheumatology
Ultrasound (US)-guided procedures have increasingly gained their role in the daily practice of rheumatology, owing to the growing evidence supporting their utility. The utilization of US guidance in procedures may enhance their accuracy, efficacy, and safety. This article presents a comprehensive review of the current evidence and practical knowledge pertaining to US-guided procedures in rheumatology, encompassing joint aspirations, injections, and other applications such as tendon sheath injections. We provide a detailed description of the US-guided procedure process and compare the in-plane and out-of-plane view methods, along with practical techniques based on existing evidence or our own expertise. For each joint, we summarize how to perform procedures with figures to facilitate a better understanding. Additionally, we introduce other applications of US-guided procedures for tendons, enthesis, bursae, and nerves as well as emerging therapies such as US-guided fascia hydrorelease. By utilizing these US techniques, rheumatologists can achieve the ability to manage a wider range of musculoskeletal conditions.
Ultrasound Guidance Is Not Superior in Subacromial Bursa and Intraarticular Injections but Superior in Bicipital Groove: A Meta-analysis of Randomized Controlled Trials
2022, Arthroscopy - Journal of Arthroscopic and Related Surgery
Citation Excerpt :
Only one study did not report sex distribution and the mean age of patients was the youngest.34 All the studies included patients with shoulder pathology, including tendonitis,26,31,33,34 tendon rupture and tears,10,24,25,31 bursitis,10,24,25,27,31, tendinosis,24 fluid accumulation,10,24 synovitis,10,25 tendon calcifications,10,24 tendonitis,10 adhesive capsulitis/frozen shoulder,23,36 acromioclavicular degeneration,24 impingement syndrome,24,25,29-31,35 periarthritis,32 and shoulder arthritis.32 Only 1 study reported stiffness of the shoulder joint due to various causes28 (Table 1).
To perform a meta-analysis comparing the clinical and functional outcomes of ultrasound-guided (USG) and blind injections for shoulder pain.
The Embase, Cochrane Library, and PubMed databases were searched from database inception to April 7, 2021. Clinical and functional outcomes included the visual analog scale (VAS) pain score, abduction, flexion, American Shoulder and Elbow Surgeons Assessment Form (ASES) score, Constant-Murley Shoulder (CMS) score, Shoulder Pain and Disability Index (SPADI), Shoulder Disability Questionnaire (SDQ) score, and Shorted Disabilities of the Arm, Shoulder and Hand (Quick DASH) score. Dichotomous outcomes were assessed with mean differences (MDs) and 95% confidence intervals (95% CIs).
Fifteen studies that compared USG and blind injections were included. No significant difference was found in the VAS score between the blind group and USG group (MD 0.41 [−0.02, 0.84]; I² = 79%; P = .06). Subgroup analysis of the brachial bicipital groove indicated that the USG group had less pain than the blind group (MD 1.50 [0.54, 2.46]; I² = 64; P = .002). The USG injection patients had better postoperative abduction (MD −3.08 [−5.19, −0.98], I² = 0, P = .004) and flexion (MD −3.36 [−5.56, −1.16]; I² = 0; P = .003) than the blind group. Additionally, the USG injection patients had better CMS scores than the blind injection patients (MD −12.95 [−25.60, −0.29]; I² = 96; P = .04). However, subgroup analysis showed no significant difference in the subacromial bursas and glenohumeral joints of CMS score (MD −13.22 [−29.93, 3.94]; I² = 97; P＜.0001). No significant difference was found in the SPADI, ASES score, or SDQ score between the groups.
Ultrasound guidance is not superior in the subacromial bursa and glenohumeral joint injections in pain or function. However, injection in the brachial bicipital groove, is still superior to blind injection of pain relief.
Level II, meta-analysis of Level I and II studies.
Ultrasound guided versus landmark guided corticosteroid injection in patients with rotator cuff syndrome: Randomised controlled trial
2018, Journal of Clinical Orthopaedics and Trauma
Citation Excerpt :
Ucucncu19 performed a study in which no specific shoulder pain cases were taken which showed Mean increment of 32.2 in US guided group and 12.2 in other group whereas this study was about specific rotator cuff syndrome. Zufferey et al.20 stated that clinical difference is evaluated at a difference of 16 to 20 points in Constant Score. In our study 11 patients in group 1 and 12 patients in group 2 achieved more than 16 points increment at 3 months follow up when compared from the baseline.
Impingement syndrome is the most common differential in a patient presenting to an orthopaedic OPD with shoulder pain. Impingement syndrome is often managed with subacromial corticosteroid injection, which can be instilled using either landmark guided (LMG) approach or with the assistance of ultrasound (US). This study was envisaged to enquire whether ultrasound assistance improves the accuracy, efficacy or safety profile of the injection.
60 patients of rotator cuff syndrome underwent diagnostic ultrasound. They were randomly assigned to receive subacromial injection of 2 ml (40 mg/ml) methylprenisolone and 2 ml of 1% lignocaine combination either by US assistance (n = 30) or using LMG assistance (n = 30). The patients were evaluated before injection and on follow up visits at day 5, week 3, week 6 and 3rd month by a single assessor. The assessor was blinded of the treatment group to which patient belonged. Clinical assessment included demographic and clinical data, accuracy of injection, VAS (0–100) for pain, Constant score with goniometer evaluation of range of motion, patient’s self assessment proforma and post injection side effects if any.
Initial demographic, clinical and US findings in the groups exhibited no significant differences. The accuracy of US guided injections (100%) was more when compared from LMG injection (93.3%). Both VAS and Constant score showed significant improvement following steroid injection up to 3 months of follow up. However the differences in the two groups were not significant suggesting comparable efficacy of the two approaches. (Mean VAS score decrease: 27.23 for US and 25.16 for LMG, p < 0.05: Mean constant score change: 14.73 for US and 15.00 for LMG, p < 0.05). The safety profile in both groups was comparable.
Although US guided injections have a higher accuracy of drug placement in the subacromial bursa, there is no difference in terms of clinical outcomes or safety profile of either of the method. Hence US guided injections seems to be unjustified, when compared to equally efficacious and cost effective LMG steroid injection
Musculoskeletal interventional procedures: With or without imaging guidance?
2016, Best Practice and Research: Clinical Rheumatology
Citation Excerpt :
There is not enough data to confirm that USGIs are more accurate than LMGIs, and further research is required to clarify this (Table 2). Five studies have evaluated the efficacy of USGIs and LMGIs into the subacromial space, and they all showed better outcomes for the USGI procedures in the short term [34–38]. However, two additional studies found that there is no difference in efficacy between accurate and inaccurate injections [27,29].
Aspiration and injection of joints and soft tissues is an indispensable skill used in everyday practice by the clinical rheumatologist. Most rheumatologists recognise that performing these procedures using anatomical landmarks is not always successful, particularly in the case of small or infrequently injected joints, bursae or tendon sheaths. Musculoskeletal ultrasound confirms the local pathological-anatomical diagnosis and is the most applicable and feasible imaging method that can be applied in clinical practice in guiding musculoskeletal interventional procedures. From 1993, there has been substantial examination of the accuracy of landmark- and imaging-guided procedures. We have searched the literature and ascertained whether imaging techniques improve the accuracy of musculoskeletal procedures and whether the accuracy of needle placement can be translated into improved clinical outcome (efficacy).
Ultrasound-guided versus blind subacromial-subdeltoid bursa injection in adults with shoulder pain: A systematic review and meta-analysis
2015, Seminars in Arthritis and Rheumatism
Citation Excerpt :
Characteristics of the enrolled studies are described in Table 1. Six studies assessed pain using a pain score [13–15,17–19] and two assessed SDQ score [15,18] at 6 weeks after injection. The analysis indicated a statistically significant decreased VAS and SDQ score difference between USG and LMG groups at this follow-up period in favor of USG [MD = 1.19, 95% CI (0.39, 1.98), P = 0.003 and MD = 5.01, 95% CI (1.82, 8.19), P = 0.02, respectively, Figs. 2 and 3].
This systematic review and meta-analysis aimed to assess the effectiveness of ultrasound-guided (USG) versus blind (landmark-guided, LMG) corticosteroid subacromial–subdeltoid bursa injection in adults with shoulder pain.
The searches were performed on PubMed, Ovid MEDLINE, Ovid EMBASE, Ovid CochraneCENTRAL, Web of Science, Google Scholar, and Scopus from database inception through March 27, 2015. Studies were included trials comparing USG versus LSG injections for the treatment of adults with subacromial–subdeltoid bursitis. Two reviewers independently performed data extraction and appraisal of the studies. The outcome measures collected were the decreased VAS and SDQ scores, the increased shoulder function scores and shoulder abduction motion range, and the effective rate at 6 weeks after injection.
Seven papers including 445 patients were reviewed; 224 received LMG injections and 221 received USG injections. There was a statistically significant difference in favor of USG for pain score [MD = 1.19, 95% CI (0.39, 1.98), P = 0.003] and SDQ score [MD = 5.01, 95% CI (1.82, 8.19), P = 0.02] at 6 weeks after injection. Also there was a statistically significant difference between the groups, with greater improvement reported of shoulder function scores [SMD = 0.89, 95% CI (0.56, 1.23), P < 0.001] and shoulder abduction motion range [MD 32.69, 95% CI (14.82, 50.56), P < 0.001] in the USG group. More effective rate was also reported with USG group and the difference was statistically significant [risk ratio = 1.6, 95% CI (1.02, 2.50), P = 0.04].
Ultrasound-guided corticosteroid injections potentially offer a significantly greater clinical improvement over blind SASD bursitis injections in adults with shoulder pain.
Effect of Perineural or Intravenous Betamethasone on Femoral Nerve Block Outcomes in Knee Arthroplasty: A Randomized, Controlled Study
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Original articleA controlled trial of the benefits of ultrasound-guided steroid injection for shoulder pain

Abstract

Objectives

Methods

Results

Conclusion

Section snippets

Patients

Results

Discussion

Disclosure of interest

Arthroscopy

J Shoulder Elbow Surg

Rev Chir Orthop Rep Appar Mot

Corticosteroid injections for painful shoulder: a meta-analysis

Br J Gen Pract

The efficacy of subacromial corticosteroid injection in the treatment of rotator cuff disease: a systematic review

J Am Acad Orthop Surg

Outcome of non-operative treatment of symptomatic rotator cuff tears monitored by magnetic resonance imaging

J Bone Joint Surg Am

Diagnostic accuracy of clinical tests for the different degrees of subacromial impingement syndrome

J Bone Joint Surg Am

Original article
A controlled trial of the benefits of ultrasound-guided steroid injection for shoulder pain