Anti-TNF (adalimumab) injection for the treatment of pain-predominant early-stage frozen shoulder: the Anti-Freaze-Feasibility randomised controlled trial.

OBJECTIVE: The Anti-Freaze-F (AFF) trial assessed the feasibility of conducting a definitive trial to determine whether intra-articular injection of adalimumab can reduce pain and improve function in people with pain-predominant early-stage frozen shoulder. DESIGN: Multicentre, randomised feasibility trial, with embedded qualitative study. SETTING: Four UK National Health Service (NHS) musculoskeletal and related physiotherapy services. PARTICIPANTS: Adults ≥18 years with new episode of shoulder pain attributable to early-stage frozen shoulder. INTERVENTIONS: Participants were randomised (centralised computer generated 1:1 allocation) to either ultrasound-guided intra-articular injection of: (1) adalimumab (160 mg) or (2) placebo (saline (0.9% sodium chloride)). Participants and outcome assessors were blinded to treatment allocation. Second injection of allocated treatment (adalimumab 80 mg) or equivalent placebo was administered 2-3 weeks later. PRIMARY FEASIBILITY OBJECTIVES: (1) Ability to screen and identify participants; (2) willingness of eligible participants to consent and be randomised; (3) practicalities of delivering the intervention; (4) SD of the Shoulder Pain and Disability Index (SPADI) score and attrition rate at 3 months. RESULTS: Between 31 May 2022 and 7 February 2023, 156 patients were screened of whom 39 (25%) were eligible. The main reasons for ineligibility were other shoulder disorder (38.5%; n=45/117) or no longer in pain-predominant frozen shoulder (33.3%; n=39/117). Of the 39 eligible patients, nine (23.1%) consented to be randomised (adalimumab n=4; placebo n=5). The main reason patients declined was because they preferred receiving steroid injection (n=13). All participants received treatment as allocated. The mean time from randomisation to first injection was 12.3 (adalimumab) and 7.2 days (placebo). Completion rates for patient-reported and clinician-assessed outcomes were 100%. CONCLUSION: This study demonstrated that current NHS musculoskeletal physiotherapy settings yielded only small numbers of participants, too few to make a trial viable. This was because many patients had passed the early stage of frozen shoulder or had already formulated a preference for treatment. TRIAL REGISTRATION NUMBER: ISRCTN 27075727, EudraCT 2021-03509-23, ClinicalTrials.gov NCT05299242 (REC 21/NE/0214).

Efficacy of hypertonic dextrose proliferation therapy in the treatment of rotator cuff lesions: a meta-analysis.

BACKGROUND: One of the most prevalent illnesses of the shoulder is rotator cuff tendinosis, which is also a major contributor to shoulder discomfort and shoulder joint dysfunction. According to statistics, rotator cuff tendinosis occurs in 0.3-5.5% of cases and affects 0.5-7.4% of people annually. It will be necessary to conduct a meta-analysis to evaluate the efficacy of hypertonic glucose proliferation therapy in the treatment of rotator cuff problems. METHODS: The databases Cochrane PubMed, Library, Web of Science and EMbase, are retrieved by the computer. Individuals with rotator cuff lesions in the intervention group were treated with hypertonic dextrose proliferation therapy, whereas individuals in the control condition were treated with a placebo. Outcome markers for rotator cuff lesions patients; Pursuant to studies, the visual analogue scale (VAS) score, the shoulder pain & disability index (SPADI), & other metrics are used to evaluate the effects of hypertonic dextrose proliferation treatment on individuals with rotator cuff diseases. After carefully evaluating the calibre of the literature, data analysis was performed utilising the RevMan 5.3 programme. RESULTS: Meta-analysis finally contained 6 papers. In six investigations, the test & control group's VAS scores improved, with the test team's score considerably outperforming the control team [standardized mean difference (SMD): 1.10; 95% Cl: 0.37,1.83; P < 0.01], shoulder pain and disability index (SPADI) score (SMD:8.13; 95% Cl: 5.34,10.91; P < 0.01), Flexion (SMD:5.73; 95% Cl: 0.99,10.47; P < 0.05), Abduction (SMD:6.49; 95% Cl: 0.66,12.31; P < 0.05), Internal rotation (SMD:-1.74; 95% Cl: -4.25,0.78; P = 0.176) and External rotation (SMD:2.78; 95% Cl: -0.13,5.69; P = 0.062). CONCLUSION: The findings of this study suggest that individuals with rotator cuff injuries may benefit from hypertonic dextrose proliferation treatment based on the visual analogue scale (VAS) score, the Shoulder Pain and Disability Index (SPADI) score, Flexion, & Abduction. These results must, nevertheless, be supported by high-caliber follow-up research.

Active gas aspiration in reducing pain after laparoscopic cholecystectomy: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Postoperative pain is a common issue following laparoscopic cholecystectomy. This meta-analysis aimed to determine if active gas aspiration is more effective than passive gas aspiration in reducing postoperative pain and analgesic requirements. METHODOLOGY: The study conducted a systematic search of various databases, including Embase, Medline, and Cochrane Central Register of Controlled Trials (CENTRAL) via Ovid. It also searched trial registries and reference lists of included studies, with no date restrictions but limited to English language, up to December 21, 2022. The study included all randomized clinical trials that had documented elective laparoscopic cholecystectomy procedure and reported at least one relevant outcome. Articles that included subdiaphragmatic drain, intraperitoneal normal saline infusion, or pulmonary recruitment maneuver were excluded from the analysis. Two reviewers independently and in duplicate assessed the eligibility of studies and extracted data. The study reported findings according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. The risk of bias of the included trials was assessed using the Revised Cochrane Risk of Bias Assessment Tool. The study used a random-effects model to pool data. RESULTS: This meta-analysis included 5 randomized clinical trials with 367 participants and found that active gas aspiration resulted in significantly lower residual gas volume and total analgesia requirements compared to passive gas aspiration. Active gas aspiration also led to significantly lower shoulder pain scores at 24 h postoperatively. However, no significant differences were observed in hospital stay duration or abdominal pain scores. CONCLUSION: The study found that active gas aspiration can be effective in reducing postoperative shoulder pain and analgesic requirements after laparoscopic cholecystectomy, which has important implications for patient care and healthcare costs. Importantly, this intervention does not impose any additional time or financial burden. However, further research is needed to evaluate its impact on other laparoscopic procedures.

Predictive Factors of Intra-articular Corticosteroid Injections With Ultrasound-Guided Posterior Capsule Approach for Patients With Primary Adhesive Capsulitis.

BACKGROUND: Adhesive capsulitis affects the shoulder joint, causing pain and limiting motion. In clinical practice, the effectiveness of injections varies, and the factors influencing their success remain unclear. This study investigates the predictors of effective corticosteroid injections in patients with primary adhesive capsulitis. DESIGN: This retrospective study enrolled adhesive capsulitis patients older than 35 yrs who received intra-articular corticosteroid injections. The response was determined based on patients' pain and range of motion 3 mos after the injection. Demographic data, medical comorbidities, and radiographic parameters (critical shoulder angle and acromial index) were compared between the effective and noneffective groups. Receiver operating characteristic curves and logistic regression were used to identify the predictors of injection effectiveness. RESULTS: This study included 325 patients with primary adhesive capsulitis, who were divided into responder (189 patients, 58.2%) and nonresponder (136 patients, 41.8%) groups. The receiver operating characteristic curve revealed that the acromial index score indicated favorable discrimination for predicting a poor response to injections, whereas the critical shoulder angle score did not. Logistic regression revealed that the pain period, diabetes mellitus, and acromial index are predictors of nonresponders to injections. CONCLUSIONS: Long pain duration, the presence of diabetes mellitus, and an acromial index score greater than 0.711 were predictors of nonresponse to corticosteroid injections for primary adhesive capsulitis 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.

Effects of adjuvant application of corticosteroid and ozone after ultrasound-guided puncture and lavage for the treatment of rotator cuff calcific tendinitis: study protocol for a non-inferiority randomized controlled trial.

BACKGROUND: Steroid injection after percutaneous irrigation of calcific deposits is a common method for the treatment of rotator cuff calcific tendinitis (RCCT). However, steroids may prevent calcification resorption and cause potentially irreversible damage to tendons. Recent studies have confirmed the positive effects of ozone injection in shoulder tendinopathies, but no RCCTs have been reported. Thus, our study aims to evaluate the non-inferiority of ozone versus steroid injection. METHODS: This is a prospective, randomized, parallel control and non-inferiority trial. A total of 100 patients with unilateral symptomatic RCCT will be enrolled and randomized in a 1:1 ratio to two groups: ultrasound-guided injection with ozone or corticosteroid. The primary outcome is the numeric rating scale for pain (NRS) at 1 week and 3 months following the procedure. Secondary outcomes include a multi-dimensional evaluation of shoulder disability and quality of life improvement, the degree of calcification absorption after treatment, and the number of multiple treatments. DISCUSSION: The results of this study will provide short-term and long-term evidence for the effectiveness of ozone treatment in RCCT in relieving pain or improving shoulder function. TRIAL REGISTRATION: Chinese Clinical Trial Registry ChiCTR2200063469. Registered on 7 September 2022.

Use of Botulinum Toxin as a Treatment of Hemiplegic Shoulder Pain Syndrome: A Randomized Trial.

OBJECTIVE: The primary objective of this paper is to assess whether the use of 200 units of abobotulinum in the pectoralis major and subscapularis muscles modifies the pain complaint assessed using the visual analog scale in subjects with shoulder pain after the onset of spastic hemiplegia due to cerebrovascular disease when compared to the application of a placebo to the same muscles. DESIGN: A prospective, double-blind, randomized, and placebo-controlled clinical trial study in two different rehabilitation centers. SETTING: Two distinct outpatient neurological rehabilitation services. PARTICIPANTS: Patients older than 18 years who were included presented upper limb spasticity resulting from ischemic or hemorrhagic stroke and a diagnosis of Painful Hemiplegic Shoulder Syndrome (PHSS) that was independent of motor dominance. INTERVENTIONS: Patients were divided into two groups, one of them underwent the application of botulinum toxin (TXB-A) in the pectoralis major and subscapularis muscles, at a total dose of 400 U. MAIN OUTCOME MEASURE: Patients were assessed for a change in pain using the Visual Analog Scale (VAS) for at least 13 mm. RESULTS: An improvement in pain and spasticity levels in both groups, more intense in the toxin group, but without statistical significance. The comparison between the groups showed a reduction in pain by VAS (p = 0.52). CONCLUSIONS: The use of botulinum toxin in the subscapularis and pectoralis major muscles resulted in a reduction in shoulder pain in spastic hemiplegic patients without statistical significance.

Comparison of corticosteroid injection, physiotherapy and combined treatment for patients with chronic subacromial bursitis - A randomised controlled trial.

OBJECTIVE: To investigate whether combination of corticosteroid subdeltoid injections and physiotherapy was more effective than either treatment alone in chronic subacromial bursitis. DESIGN: Prospective, three-arm randomised controlled trial. SETTING: Rehabilitation department of an academic hospital. SUBJECTS: Patients with chronic subacromial bursitis. INTERVENTIONS: Patients were divided into corticosteroid injection (N = 36), physiotherapy (N = 40) and combined (N = 35) groups. Two corticosteroid subdeltoid injections in corticosteroid group, 8-week physical therapy emphasising on therapeutic exercise in physiotherapy group, and combined both treatments in combined group. MAIN OUTCOME MEASURES: The primary outcome measures were pain visual analogue scale and Shoulder Pain and Disability Index at 8 weeks after finishing treatment. The secondary outcome measures were active range of motion, Shoulder Disability Questionnaire, Western Ontario Rotator Cuff Index, patient's evaluation of treatment effect, and symptom recurrence. RESULTS: Group comparison showed significant statistical difference in shoulder flexion (P < 0.003) and patient's evaluation of treatment effect (P < 0.001). The time and group interactions comparison revealed significant statistical differences in pain score (P < 0.024), external rotation (P < 0.044) and patient's evaluation of treatment effect (P < 0.001). The above statistics were in favour of the corticosteroid and combined groups rather than physiotherapy group. The percentage of recurrence was 36.1, 7.5 and 17.1 in the corticosteroid, physiotherapy and combined groups, respectively (P < 0.001). CONCLUSION: Corticosteroid subdeltoid injection, or combined with physiotherapy, was superior to physiotherapy alone, but the recurrence rate was least in the physiotherapy group.

Comparison Clinical Effects of Hypertonic Dextrose and Steroid Injections on Chronic Subacromial Bursitis: A Double-Blind Randomized Controlled Trial.

OBJECTIVE: The aim of the study is to determine and compare the treatment efficacy of subacromial steroid injections and dextrose prolotherapy for chronic subacromial bursitis patients. DESIGN: Fifty-four patients with chronic subacromial bursitis were enrolled in this double-blind randomized controlled trial. Shoulder Pain and Disability Index and visual analog scale were the primary outcomes. RESULTS: The steroid group ( n = 26) exhibited significant visual analog scale score improvements comparing with baseline at weeks 2, 6, and 12; the dextrose prolotherapy group ( n = 28) exhibited visual analog scale score improvements at weeks 6 and 12. The steroid group displayed significant Shoulder Pain and Disability Index score improvements compared with baseline at weeks 2, 6, and 12; the dextrose prolotherapy group exhibited significant score decreases at weeks 2 and 6. Compared with the dextrose prolotherapy group, the steroid group demonstrated significantly greater decreases in visual analog scale scores at weeks 2 and 6; the steroid group showed significantly greater decreases in Shoulder Pain and Disability Index scores at weeks 2, 6, and 12. CONCLUSIONS: Both hypertonic dextrose prolotherapy and steroid injections can provide short-term improvements of pain and disability among chronic subacromial bursitis patients. Moreover, steroid injections showed better effectiveness than hypertonic dextrose prolotherapy in ameliorating pain and improving function.

Knowledge and appropriateness of care of family physicians and physiotherapists in the management of shoulder pain: a survey study in the province of Quebec, Canada.

BACKGROUND: Shoulder pain is difficult to diagnose and treat with half of those affected still symptomatic six months after initial consultation. This may be explained by primary care management not conforming to evidence-based practice. This survey evaluated physiotherapists (PTs) and family physicians' (FPs) knowledge and appropriateness of care in shoulder pain management. METHODS: A survey sent to PTs and FPs in the province of Quebec, Canada presented four clinical vignettes with cases of rotator cuff (RC) tendinopathy, acute full-thickness RC tear, adhesive capsulitis and traumatic anterior glenohumeral instability. Respondents indicated diagnosis, indications for imaging, specialists' referrals, and choice of treatments. Answers were compared to recommendations from clinical practice guidelines (CPGs). Participants' responses were compared between types of providers with Fisher's exact test. RESULTS: Respondents (PTs = 175, FPs = 76) were mostly women with less than ten years of experience. More than 80% of PTs and 84% of FPs correctly diagnosed cases presented. Despite this practice not being recommended, more FPs than PTs recommended an imaging test in the initial management of RC tendinopathy (30% compared to 13%, p = 0.001) and adhesive capsulitis (51% compared to 22%, p = 0.02). For full-thickness RC tear and shoulder instability, up to 72% of FPs and 67% of PTs did not refer to a specialist for a surgical opinion, although recommended by CPGs. For RC tendinopathy, 26% of FPs and 2% of PTs (p < 0.001) would have prescribed a corticosteroid infiltration, which is not recommended in the initial management of this disorder. For adhesive capsulitis, significantly more FPs (76%) than PTs (62%) (p < 0.001) suggested an intra-articular corticosteroid infiltration, as recommended by CPGs. For all presented vignettes, up to 95% of family physicians adequately indicated they would refer patients for physiotherapy. In prioritizing rehabilitation interventions, up to 42% of PTs did not consider active exercises as a priority and up to 65% selected passive modalities that are not recommended for all shoulder pain vignettes. CONCLUSIONS: Most FPs and PTs were able to make adequate diagnoses and select appropriate treatments for shoulder pain, but practices opposed to evidence-based recommendations were chosen by several respondents. Further training of FPs and PTs may be needed to optimize primary care management of different shoulder disorders.

Extracorporeal Shock Wave Therapy vs. Corticosteroid Local Injection in Shoulder Impingement Syndrome : A Three-Arm Randomized Controlled Trial.

OBJECTIVE: The aim of this study was to examine the effects of combining extracorporeal shock wave therapy or local corticosteroid injections with a conventional physical therapy (CPT) program for patients with shoulder impingement syndrome. DESIGN: This was a prospective single-blinded, randomized controlled study. METHODS: Sixty patients with unilateral shoulder impingement syndrome >3 mos were allocated to group A (a 4-wk program of CPT plus a single local corticosteroid injection of 40 mg triamcinolone acetonide mixed with 1% xylocaine, n = 20), group B (CPT only, n = 20), and group C (CPT plus extracorporeal shock wave therapy, 2000 impulses, 0.2-0.3 mJ/mm 2 , one session per week for 3 wks, n = 20). Subacromial space, shoulder pain and disability index, and shoulder range of motion were assessed at baseline and 4 and 12 wks posttreatment. RESULTS: There were no between-group differences at 4 wks. At the 12-wk follow-up, no significant differences were found between groups A and B. There was a significant difference in favor of group C compared with group A with the expectation of shoulder internal rotation and subacromial space. Group C was also superior to group B in all outcomes except for subacromial space. CONCLUSION: The addition of extracorporeal shock wave therapy to CPT induced more noticeable intermediate-term effects than CPT plus local corticosteroid injection or CPT alone.

Effectiveness of lyophilized growth factors injection for subacromial impingement syndrome: a prospective randomized double-blind placebo-controlled study.

BACKGROUND: Platelet-derived lyophilized growth factors (L-GFs) use a standardized number of allogenic pathogen-free platelets instead of autologous platelets used in PRP as a source of growth factors. This study aimed to evaluate the efficacy of L-GF injection versus placebo in subacromial impingement (SIS) treatment. METHODS: The current randomized double-blind placebo-controlled study included sixty patients (40 females and 20 males, aged between 24 and 75 years) diagnosed with SIS (both clinically and sonographically). Patients were randomly assigned to two equal groups. Under ultrasound guidance, group 1 received subacromial saline injection, and group 2 received L-GF injection. Clinical examination, pain visual analogue scale (VAS), shoulder pain and disability index (SPADI) and shoulder ultrasound were performed before and at the 8th week after injection. RESULTS: Follow-up assessment showed statistically significant improvement in the L-GF group regarding active flexion, active and passive internal rotation and extension, SPADI-disability scale, VAS and thickness of the supraspinatus tendon by US. Regression analysis showed that group 1 was approximately 30 times more likely than the L-GF group to experience painful arc at follow-up. Both groups showed statistically significant improvement in SPADI-pain scale and SPADI-total, flexion and abduction (still the mean value of abduction was significantly higher in the L-GF group). CONCLUSIONS: L-GF injection resulted in clinically significant reductions in pain and functional disability outcomes in patients with SIS. An objective significant reduction in the thickness of the supraspinatus tendon, measured by ultrasound, in the L-GF group hopefully encourages proper healing and functioning in SIS. TRIAL REGISTRATION: The identification number is NCT04330027, date of first registration (01/04/2020). Unique on 21/11/2019, Protocol ID: 0106178.

Immediate response to injection is associated with conservative care outcomes at 12 weeks in subacromial shoulder pain.

BACKGROUND: Subacromial injection is known to influence pain of subacromial origin, yet its association with conservative care outcomes is unknown. This study investigated whether immediate response to subacromial injection of corticosteroid and local anaesthetic is associated with conservative care outcomes at 12 weeks post injection and/or progression to surgery. DESIGN: prospective prognostic cohort study. METHODS: Sixty-four participants with subacromial related shoulder pain attending initial orthopaedic outpatient appointment at an Australian public hospital, received subacromial injection of corticosteroid and local anaesthetic followed by up to 12 weeks of physiotherapy. Immediate response to injection was measured by change in shoulder range of motion (ROM) and pain immediately (within 20 min) before and after injection. The Shoulder Pain and Disability Index (SPADI) was measured at baseline, 6 and 12-weeks. RESULTS: Backward stepwise linear regression revealed immediate post-injection improvement in pain-free ROM (p = 0.001) and higher baseline symptoms (p = 0.016) were significantly associated with better 12-week SPADI outcomes. Longer symptom duration (p = 0.029) and higher age (p = 0.013) were significantly associated with poorer outcomes. Only 11 individuals progressed to surgery. The resultant model could explain 35% of the variation in change in SPADI at 12 weeks. CONCLUSION: Improvement in pain-free shoulder ROM immediately post injection is significantly associated with better 12-week conservative care outcomes. This information, derived from within consultation injection responses, could help inform decisions about potential treatment options. Further research with higher numbers and longer-term patient-reported outcomes could further clarify these findings. REGISTRATION: Australia and New Zealand Clinical Trials Registry 21 May 2012: 12612000532808.

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.

Comparing the effect of physiotherapy and physiotherapy plus corticosteroid injection on pain intensity, disability, quality of life, and treatment effectiveness in patients with Subacromial Pain Syndrome: a randomized controlled trial.

PURPOSE: To compare the short and medium-term effects of physiotherapy plus corticosteroid injection (combined) with physiotherapy alone on pain intensity, disability, Quality of Life (QoL), and treatment effectiveness in patients with Subacromial Pain Syndrome (SAPS). METHODS: In this double-blind, parallel Randomized Controlled Trial (RCT), 50 patients with SAPS were randomly assigned into combined (N = 25, a single injection 3-6 days before physiotherapy) and physiotherapy alone group (N = 25). Pain, disability, QoL, and treatment-effectiveness were measured at pre-intervention, post-intervention, and 3 and 6-month follow-up with Visual Analog Scale (VAS), Shortened Disability of the Arm, Shoulder, and Hand (Quick-DASH), Shoulder Pain and Disability Index (SPADI) (primary outcome measure), Western Ontario Rotator Cuff (WORC), and Global Rating of Change (GRC) respectively. A 2 × 4 (group × time) mixed model analysis of variance (ANOVA) was applied for analysis. RESULTS: The ANOVA revealed statistically significant group-in-time interaction for all outcome measures (p-value < 0.05). The independent t-test showed more effectiveness in the combined group at medium-term, as the mean scores of almost all outcome measures were substantially lesser (p < 0.01). Moreover, in short-time, despite a greater number of patients stating "completely recovered" in the combined group, there was no statistically significant difference between groups. CONCLUSIONS: Effects of physiotherapy plus corticosteroid injection could be more long-lasting than physiotherapy alone in improving pain intensity, disability, QoL, and treatment effectiveness in patients with SAPS. TRIAL REGISTRATION NUMBER: IRCT20201010048980N1.IMPLICATIONS FOR REHABILITATIONShoulder pain is common, persistent, and predominantly results from subacromial pain syndrome (SAPS).Physiotherapy and corticosteroid injections are effective interventions for this condition.Comprehensive physiotherapy alone can be as effective as corticosteroid injection combined with physiotherapy in the short term.A combined approach versus physiotherapy alone may have more medium-term effects on SAPS patients' pain, disability, quality of life, and treatment effectiveness.

Subacromial impingement syndrome: association of multiple magnetic resonance imaging parameters with shoulder function and pain.

INTRODUCTION: Shoulder pain is one of the most common complaints in orthopaedics. This study focusses on the relationship between shoulder function in subacromial impingement syndrome and imaging criteria in magnetic resonance imaging (MRI). MATERIALS AND METHODS: This prospective clinical trial included 69 patients treated for subacromial impingement syndrome. Shoulder function (Constant Score, range of abduction, abduction force) and pain were correlated with the following MRI parameters: tendinosis of the rotator cuff, "halo-sign" around the biceps tendon, subacromial distance, critical shoulder angle, size of subacromial osteophytic spurs and maximum width of subacromial and subdeltoid bursa. Statistical analyses included Pearson's and Spearman's coefficients of correlation, multiple regression analysis and Student's t-test. RESULTS: The Constant Score was correlated positively with the critical shoulder angle (r = 0.313; p = 0.009) and inversely with a "halo-sign" around the biceps tendon (rho = -0.384; p = 0.001). There was no significant correlation between spur size and shoulder function, but the size of the subacromial and subdeltoid bursae was positively correlated with the subacromial spur's size (subacromial bursa: coronal plane: r = 0.327; p = 0.006; sagittal view: r = 0.305; p = 0.011; subdeltoid bursa coronal view: r = 0.333 p = 0.005). The width of the subdeltoid bursa in coronal plane was positively correlated with shoulder pain (r = 0.248; p = 0.004) and negatively with the range of abduction (r = -0.270; p = 0.025), as well as the mean (r = -0.332; p = 0.005) and maximum (r = -0.334; p = 0.005) abduction force. CONCLUSIONS: Shoulder function and pain in subacromial impingement are best predicted by the width of the subdeltoid bursa measured in the coronal MRI plane as an indicator of bursitis as well as the presence of a "halo-sign" around the biceps tendon indicating glenohumeral joint effusion. Presence of a subacromial spur could lead to subacromial and subdeltoid bursitis, which impairs shoulder function. Shoulder function seems not to be compromised by the presence of a subacromial spur in absence of bursitis. This study was registered at the German Clinical Trials Register on 08 February 2013 (ID: DRKS00011548).

The effectiveness of comprehensive physiotherapy compared with corticosteroid injection on pain, disability, treatment effectiveness, and quality of life in patients with subacromial pain syndrome: a parallel, single-blind, randomized controlled trial.

OBJECTIVE: Comparing short- and long-term effects of comprehensive physiotherapy (CP) and subacromial corticosteroid injection (SCI) on pain, disability, and quality of life in the patients with subacromial pain syndrome (SAPS). DESIGN: 2 × 4 randomized controlled trial. PARTICIPANTS: 50 participants with unilateral SAPS. INTERVENTION: Random assignment with allocation concealment into two groups labeled as 12 sessions, supervised CP (n = 22) and 1cc triamhexal SCI (n = 25). OUTCOMES: Visual Analog Scale (VAS), Shoulder Pain and Disability Index (SPADI), shortened Disabilities of Arm, Shoulder and Hand (Quick-DASH), and Western Ontario Rotator Cuff Index (WORC). Outcomes were gathered pre- and post-intervention, with three- and six-month follow-ups. RESULTS: Variance analysis revealed that there was a significant interaction of group-in-time for SPADI and WORC (P < .05) but not for Quick-DASH and VAS (P > .05). The independent t-test analysis showed that the mean scores of all outcome measures in CP group were lesser than SCI group via 6 months (P < .05), except for the VAS (P > .05, mean difference = -0.97, 95% confidence interval -2.11-0.15). CONCLUSION: CP results in statistically significant and potentially clinically important difference in function and quality of the life at all timeframe. Moreover, there was no between group difference in order to reduce pain.

Peripheral sensitization is demonstrated in subacromial pain syndrome, with central sensitization found only in females.

The objective of this study was to explore whether hypersensitivity in patients with subacromial pain syndrome (SPS) manifests purely as localized peripheral sensitization or central sensitization, is influenced by the presence of subacromial pain, and presents similarly in male and female patients. Pressure pain threshold was assessed in both a patient cohort with unilateral SPS and an uninjured matched control group. Control subjects were assessed twice, with a 15 minute rest period between testing, while patients were assessed at baseline and after an almost instantaneous reduction in pain arising from an anesthetic injection in patients. Patients received a subacromial injection consisting of both anesthetics (3 cc of 2% lidocaine and 6 cc 0.5% Marcaine with Epinephrine) and a corticosteroid agent (1 cc DepoMedrol). Patients demonstrated hypersensitivity across the involved shoulder only, providing evidence for peripheral sensitization. There were trends for hypersensitivity across remote joints, however when separated by sex, only female patients demonstrated both peripheral and central sensitization. Immediate pain reduction had no influence on hypersensitivity in the short-term. Clinical Significance: Neuropathic components are likely present in some patients with subacromial pain syndrome, and female patients may be particularly at risk for presenting with neuropathic pain. These findings are applicable towards understanding the heterogeneous etiology underlying subacromial pain syndrome and informing clinical management.

Systematic review and meta-analysis on the effectiveness of ultrasound-guided versus landmark corticosteroid injection in the treatment of shoulder pain: an update.

BACKGROUND: Corticosteroid (CS) can be injected in a blind fashion (landmark-guided) or with ultrasound (US) guidance, and this may contribute to varying clinical results. We conducted this systematic review and meta-analysis to assess the effectiveness of US-guided versus landmark CS injections in the treatment of adult patients with shoulder pain. METHODS: We searched MEDLINE (via PubMed), Scopus, Web of Science, EBSCO, and Cochrane Library for randomized controlled trials (RCTs) comparing US-guided versus landmark CS injection regarding visual analogue scale (VAS), functional scores, disability scores, abduction degree, and side effects. The data were pooled as mean difference (MD), standardized mean difference (SMD), or risk ratios (RRs), with 95% confidence intervals (CIs), using R software (meta package 4.9-0) for windows. Subgroup analysis and leave-one-out analysis were conducted. RESULTS: Eighteen RCTs, with a total of 1010 patients, were included in this meta-analysis. The pooled estimate favored the US-guided over landmark CS injection in terms of the mean change of VAS between 6 weeks and baseline (SMD = - 0.48, 95% CI [- 0.79, - 0.17]), the shoulder functional scores (SMD = 0.35, 95% CI [0.05, 0.65]) and shoulder abduction degree (MD = 8.78, 95% CI [3.11, 14.46]). Whilst no significant difference was found between the compared group regarding the overall shoulder disability scores (SMD = - 0.51, 95% CI (- 1.25, 0.22]) and side effects (RR = 0.45, 95% CI [0.15, 1.34]). None of the eligible study analyzed the cost-effectiveness of the US-guided method compared with the landmark method for CS injection. CONCLUSION: Our analysis showed that US-guided CS injection was effective in the treatment of various shoulder diseases. Further research on the cost-effectiveness of US-guided CS methods is needed.