REVIEW shoulder cover

Evidence-Based Insights on Shoulder Injections

introduction

After previously comparing corticosteroids and examining common complications, we will now examine the evidence behind corticosteroid injections. This article will cover some of the randomized controlled trials behind shoulder injections including adhesive capsulitis, subacromial impingement and biceps tendonitis.  Injections with depot corticosteroids are used by many to provide both therapeutic and diagnostic value.  They can also serve to delay or possibly avoid the need for surgery in some situations.

adhesive capsulitis

Adhesive capsulitis commonly presents with progressive pain and limited range of motion.  It can also occur overnight after a day of housework, painting or overhead lifting.  It can affect 2-5 percent of the general population and up to 20% of diabetics [1].  It is generally self-limiting, but some patients have reported pain for up to 3 years [2].  The goals of treatment include relieving pain and restoring motion and function.  Common first line treatments include NSAIDs, physical therapy and corticosteroid injections.  Subacromial injections are widely used for treatment due to its cost-effectiveness and often quick partial relief of pain.  Adhesive capsulitis is thought to be due to inflammation and corticosteroids are proposed to reduce synovitis, limit capsular fibrosis and alter the natural history of the disease [3-5].

Adhesive capsulitis MRI

Image 1: MRI findings related to adhesive capsulitis.  Adopted from [41].

A review in 2012 compared the effectiveness of corticosteroids with physical therapy and found greater improvement in pain, ROM and shoulder disability after six weeks and one year, with a greater effect at six weeks [2].  A recent review in 2016 concluded that corticosteroid injections (mostly with triamcinolone 20 mg or 40 mg) outperformed physical therapy in regards to shoulder pain and function up to 12 weeks, but evidence for relief after 12 weeks has not been supported [6].  A study by Carette et al. concluded that the use of an intra-articular corticosteroid injection (CSI) in addition to physical therapy showed greater improvement in pain and disability when compared to physical therapy or placebo at six weeks and three months, but this was not significant at six months.  The use of physical therapy alone was found to be of limited benefit in this study [7]. 

Another meta-analysis of 319 studies concluded that arthrographic distension or hydrodilatation with corticosteroid provides superior pain relief in the short term and improvement in range of motion across all time frames for frozen shoulder when compared to CSI or physiotherapy [38].  Intra-articular CSI and arthrographic distension/hydrodilatation with corticosteroid provide advantages over placebo in short-term pain relief, range of motion (ROM) and shoulder function, with improvements in ROM continuing into the medium and long term [38].

However, there was one more recent study where about 80 patients that used PNF, or proprioceptive neuromuscular facilitation (PNF), in the therapy group and ROM improved more in early stages of the disease when compared to corticosteroid injections. Pain relief and disability were less in this study with the corticosteroid injection at 6 weeks [8]. When comparing dosages, 40 mg of triamcinolone acetonide outperformed 10 mg, but had similar results to 20 mg [9].  Another meta-analysis also concluded that PNF is superior to conventional physical therapy [38].

There have also been studies comparing location of injections for adhesive capsulitis.  Oh et al. compared visual analog scale for pain, passive ROM and the Constant-Murley score (100 point scoring system based on many parameters including pain, strength, ability to perform ADLs) for glenohumeral joint injections and subacromial injections.  No significant difference was found at 3,6 and 12 weeks [10].  Shin et al. compared visual analog scale and functional outcomes in groups including subacromial space injection, glenohumeral injection, subacromial space+glenohumeral injections and medication.   The study found no difference between the injection groups at 24 week follow up, but injections were again found to be superior to medication alone [11].

For adhesive capsulitis, injection therapy with corticosteroids has consistently outperformed physical therapy alone and medication therapy alone.  For capable providers, hydrodilatation has been shown overall recently to be the most effective conservative treatment for adhesive capsulitis [38].  This was found to be significant up to 12 months in some studies and the benefit seems to become less significant as time passes.  Corticosteroid injections are a relatively safe option with the most common side effects including pain at injection site and facial flushing [12]. 

subacromial impingement

Subacromial impingement has changed in meaning over the past decade and is generally thought of as atraumatic, usually unilateral shoulder problem that causes pain that is worse when abducting the arm.  Different clinical names have been given including bursitis, supraspinatus tendinopathy, tendon cuff degeneration and tendinosis calcarea [13].  For this reason, it is the most common diagnosis in patients with shoulder [14].  Management typically begins with physical therapy and NSAIDs, although the evidence in response to this treatment is rated as poor.  NSAIDs, physical therapy and corticosteroid injections have all been shown to be superior to placebo [15].  Another recent 2019 randomized trial showed benefit of platelet rich plasma for subacromial impingement syndrome [39].

Subacromial impingement anatomy

Figure 2.  Subacromial impingement mechanisms.  Adopted from [42].

When conservative management fails, many providers will attempt a subacromial injection as an adjunct.  Corticosteroid injections were found to be superior to placebo in terms of visual analog scale, shoulder function, pain with daily activities and disturbance of sleep after 4 weeks [16]. They were found to have a significant benefit when compared to placebo for 3 to 38 weeks in a 2005 meta-analysis [18].  A meta analysis in 2009 showed subacromial injections were also found to have a significant effect for up to 8 weeks, but the effect was comparable to oral NSAIDs [17].  Another study in 2010 showed injection therapy with physical therapy to be more effective in pain and function scores when compared to physical therapy alone in 232 patients with the mean age of 56 at 1 week and 6 weeks [19].  Positive effects greater than 8-12 weeks have yet to be shown.

There are also contrasting studies, including a randomized controlled trial of 106 patients, which concluded there were no important differences in short term outcomes between ultrasound guided corticosteroid subacromial injections and systemic corticosteroid injections for rotator cuff disease [20].  A 2003 Cochrane review concluded that subacromial injections were better than placebo in the short term, but offered no benefit over oral NSAID therapy [21].

There is also disagreement on whether or not ultrasound guidance should be used if available.  There are at least five level two studies that showed superior results with ultrasound guidance compared to landmark guided injections [22-26].  A 2015 meta-analysis with seven randomized controlled trials included improved pain and function scores at 6 weeks with ultrasound-guided injections27.  There are also at least four reports concluding there was no clinically significant difference when using ultrasound guidance [28-31].  The average accuracy of ultrasound injections was between 70 and 80 percent in these studies.  One of the arguments made is that if one is using ultrasound guidance, a skilled MSK interventionist would have one hundred percent accuracy [32].

More recently, a meta-analysis comparing ten studies using ketorolac have shown they are as effective as SCIs for short-term pain relief and improving function in patients with subacromial impingement syndrome [40]. In addition, ketorolac is less expensive and causes no major difference in complications.  What seems like fairly uncommon practice and similar to evidence with knees, ketorolac provides a viable, cost-effective alternative for injection therapy in patients with subacromial impingement syndrome [40].

Another possible tool for sports medicine practitioners is the ultrasound (US).  One large meta-analysis showed that ultrasound has a high accuracy for the diagnosis of distal forearm fractures in children when used by proper viewing method [17]. One of the main advantages is the absence of exposure to ionizing radiation. Because children are up to four times more radiation sensitive and have a higher risk of being exposed to cumulative doses of radiation over time [5–9], ultrasound has received greater interest in this age group.

In summary, most clinicians tend to prescribe a trial of conservative therapy for subacromial impingement symptoms.  Physical therapy, NSAID therapy and injection therapies have all been shown to be superior to placebo and improve pain and function.  Most studies agree there is a benefit to a subacromial injection for at least four weeks, but relief beyond that is debatable.  There are also contrasting studies on whether ultrasound guidance is superior to landmark guided subacromial injections.

biceps tendonitis

Biceps tendonitis, which mainly affects the long head of the biceps tendon, is a common source of pathology for overhead athletes and frequently coincides with superior labrum tears, or SLAP tears.  Conservative management with NSAIDS, physical therapy and activity modification is typically first line treatment [33].  There is much less data on injections for biceps tendonitis and most of these injections are performed with ultrasound guidance.  One study showed an accuracy difference of 87% with ultrasound vs 27% with landmark guided injections [34]. One low quality trial showed greater pain relief with ultrasound guidance when compared to landmark guided biceps tendon sheath injections [35].  There are a few case reports of biceps tendon rupture after injection directly into the biceps tendon and not in the tendon sheath [36,37].  Another recent 2020 randomized study compared palpation versus US guided biceps tendon sheath injections and showed improvement in pain and function in both groups at 4 weeks and 6 months [40].

Rotator cuff anatomy

Image : Rotator cuff anatomy anterior.  Adopted from [43].

Greenstick fractures generally receive conservative management. Minimally displaced or non-displaced fractures should be splinted and then subsequently placed in short arm casts. Children under 5 with distal radius greenstick fractures can tolerate up to 35 degrees of lateral angulation and 10 degrees of AP angulation. Children between 5 to 10 years of age can tolerate up to 25 degrees of lateral angulation and 10 degrees of AP angulation. Children older than ten should have reduction to less than 20 degrees of lateral angulation and 0 degrees of AP angulation. Distal radius greenstick fractures should generally be left in a short arm cast for 4-6 weeks.

Injections into the tendon sheath can be diagnostic and therapeutic by providing the physician information about the patient’s pathology based on their pain response post-treatment.  However, most clinicians view biceps tendon injections as short term therapy and feel it is imperative to work to strengthen the surrounding structures and alter throwing mechanics, if that is felt to be a part of the problem. 

Summary

In summary, strong evidence exists for the use of corticosteroids for adhesive capsulitis and subacromial impingement for short term pain relief.  Hydrodilitation with corticosteroids for adhesive capsulitis seems to be gaining traction for the best conservative treatment for adhesive capsulitis.  Subacromial corticosteroid injections remain a staple in treating subacromial impingement syndrome conservatively.  More studies are needs to further evaluate the role of corticosteroids for biceps tendinosis.

– Read more shoulder pain: https://www.sportsmedreview.com/by-joint/shoulder/

– More shoulder pain @ Wiki Sports Medicine: https://wikism.org/Shoulder_Pain_Main

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