Periarthritis of the shoulder: a controlled trial of physiotherapy. A prospective double blind dummy placebo controlled study comparing triamcinolone hexacetonide injection with oral diclofenac 50 mg TDS in patients with rotator cuff tendinitis. Treatment of "frozen shoulder" with distension and glucorticoid compared with glucorticoid alone. A randomised controlled trial. Rotator cuff tendinitis: comparison of subacromial injection of a long acting corticosteroid versus oral indomethacin therapy. Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis. A placebo-controlled trial of steroid injections in the treatment of supraspinatus tendonitis. Comparison of injection techniques for shoulder pain: results of a double blind, randomised study. Clinical study comparing acupuncture, physiotherapy, injection and oral anti-inflammatory therapy in shoulder-cuff lesions. Intra-articular triamcinolone acetonide injection in patients with capsulitis of the shoulder: a comparative study of two dose regimens. Effectiveness of corticosteroid injections versus physiotherapy for treatment of painful stiff shoulder in primary care: randomised trial. Clinical evaluation of sodium hyaluronate for the treatment of patients with rotator cuff tear. Injections and physiotherapy for the painful stiff shoulder. Corticosteroid injections in adhesive capsulitis: investigation of their value and site. Manipulation under anesthesia for frozen shoulder with and without steroid injection. Local anaesthetic injection with and without corticosteroids for subacromial impingement syndrome. Ernest Fletcher Lecture. The painful shoulder. A double-blind trial comparing subacromial methylprednisolone and lignocaine in acute rotator cuff tendinitis. Efficacy of injections of corticosteroids for subacromial impingement syndrome. Frozen shoulder: prospective clinical study with an evaluation of three treatment regimens.
nan A prospective double blind placebo controlled study was carried out to compare the effects of subacromial injection of triamcinolone and oral diclofenac in patients with rotator cuff tendinitis over a 4-week period. Both forms of treatment were superior to placebo in reducing pain, improving active abduction and reducing functional limitation. Triamcinolone showed the greatest effect in these respects, and was significantly superior to diclofenac when patients showing improvements in all 3 variables together (responders) were considered. This study is a comparison of treatments of idiopathic "Frozen Shoulder" (adhesive capsulitis), distension combined with steroid is compared with steroid alone. Evaluation was based on pain scales, analgesic usage, and range of motion outcome scales. Out of one-hundred twenty patients (age, mean 51, range 21-70) that were referred under the diagnosis FS, twenty-six fulfilled the criteria for inclusion in the study, but four patients did not want to participate in the trial, giving a total of 22 patients (age, mean 53, range 40-65) in the study. Patients were randomised by the envelope method. Two patients dropped-out, one in each treatment group thus leaving the study with 20 patients for the final statistical analysis. Eight were treated with steroid alone and 12 with distension combined with steroid. Patients received one treatment per week for a six weeks period with a follow-up at 12 weeks. They were evaluated by pain VAS on function and at rest within the study period, the different ranges of motion (ROM) were measured at inclusion time and subsequent afterwards at 3, 6, and 12 weeks. The VAS outcomes showed no difference between the treatments (VAS-function p=0,1; VAS-rest p=0.1), while in the distension group ROM showed significant improvement in all directions except extension (external p=0.0007, flexion p=0.03, extension p=0,01). The analgesic usage was significantly lower in the group treated with distension at the end of the study (p=0.008). A blinded clinical assessment of ROM also showed significant improvement (p=0.002). It is concluded that distension with steroid can seem to help in management of "Frozen Shoulder". Other studies seems to support the conclusion. Using a prospective, double blind, double dummy protocol, we compared the efficacy of subacromial injection of 40 mg of triamcinalone acetonide versus oral indomethacin, 100 mg/day, in 40 patients with acute rotator cuff tendinitis. Repeat injection and refill of medication was given after 3 weeks, if necessary. At 6 weeks, there was no significant difference between the 2 groups with respect to the percentage of patients who improved (60 vs 66%) or the magnitude of the change of pain and motion variables. This study suggests that there is essentially no difference in the short term efficacy of oral nonsteroidal therapy compared to local corticosteroid injection(s) in the treatment of rotator cuff tendinitis. Adhesive capsulitis is a common musculoskeletal disorder mainly affecting middle aged adults. It is associated with generalized pain and tenderness in the shoulder joint with severe loss of active and passive ranges of motion in all planes. The aim of this study was to compare the efficacy of local steroid injection and physical therapy measures for treating this disorder. Ten male and 10 female patients were enrolled in the study. The patients were divided randomly into two groups and treated with either 40 mg methylprednisolone acetate injection with local anesthetic (group A) or physical therapy measures plus nonsteroidal anti-inflammatory drugs (group B). The mean ages of the patients were 55.6+/-12.2 years in group A and 56.4+/-7.1 years in group B. Clinical assessment was performed on initial visit and at the 2nd and 12th weeks. Active and passive range of motion was recorded and the visual analogue scale was used to evaluate pain intensity. At initial visit, these data in both groups of patients were not statistically different. Although both treatment regimens resulted in significant improvement in range of motion, the differences between mean external rotation at the 2nd and 12th weeks were not statistically significant in either group. The improvement in range of motion at the end of the study was similar in both groups (P>0.05). All patients reported improvement during the study. The differences between mean VAS scores at the 2nd and 12th weeks were statistically significant in both groups. In conclusion, local steroid injection therapy was found to be as effective as physical therapy for the treatment of adhesive capsulitis. In this report of a double-blind placebo-controlled trial of steroid injections for supraspinatus tendonitis, there was no statistical difference in the improvement in pain score between the two groups at 2 and 8 weeks of follow-up or in analgesic consumption. This trial casts further doubt on the efficacy of such treatment in soft tissue lesions around the shoulder. Seventy seven patients with soft tissue shoulder lesions including adhesive capsulitis and disorders of the rotator cuff and acromioclavicular joint were admitted to a trial comparing two different methods of corticosteroid injection with local anaesthetic in a randomly allocated double blind study. The method of anatomical injection after diagnosis by the technique of selective tissue tension gave 60% success compared with the method using tender or trigger point localisation, giving 20% success (p less than 0.001). In a single-blind trial, five treatments for painful stiff shoulder were compared for a 4-week assessment period in 60 patients. The treatments were acupuncture, steroid injection with placebo and with active tolmetin sodium, physiotherapy in the form of ultrasound and 'placebo' physiotherapy with placebo tolmetin sodium. Objective assessment was gained by use of goniometer readings to monitor shoulder abduction. Pain was measured by visual analogue scales and by a 4-point scale. Comparative assessment was also recorded and at the end of the study a success or failure was recorded for each patient's treatment. With very few exceptions all patients improved markedly, both in terms of the subjective and objective parameters. No differences between the treatments were detected. The incidence and severity of side-effects was low. It is suggested that the results show that the painful stiff shoulder may be a self-limiting condition and that any beneficial effect was really due to natural recovery. This is an important consideration because patients do not always receive immediate attention when referred to an out-patient department and the use of physiotherapy and acupuncture in such cases, perhaps, should be critically examined. Although corticosteroid injections have been reported to be effective in capsulitis of the shoulder, the optimal dose has not been established. The purpose of this study was to compare relief of symptoms following a lower dose with that following a higher dose of triamcinolone acetonide given intra-articularly.
                Thirty-two patients were given low dose suspension; 25 patients were given high dose suspension.
                Randomized, double-blind clinical trial. Each patient was given a course of three injections. Pain, sleep disturbance, functional impairment and passive range of motion (ROM) were assessed at intake and at one, three and six weeks after the initial injection. Data were analysed by independent sample t-tests and nonparametric Mann-Whitney U-tests.
                The group which received the 40 mg dose showed significantly greater improvement than the group receiving the 10 mg dose.
                The study shows that in the treatment of frozen shoulder greater symptom relief is obtained with a dose of 40 mg triamcinolone acetonide intra-articularly than with a dose of 10 mg. The effect on pain and sleep disturbance was more marked than on ROM. Intra-articular injections with triamcinolone acetonide appear to be an effective method to obtain symptom relief for patients with painful capsulitis of the shoulder. To compare the effectiveness of corticosteroid injections with physiotherapy for the treatment of painful stiff shoulder.
                Randomised trial.
                40 general practices.
                109 patients consulting general practitioners for shoulder pain were enrolled in the trial.
                Patients were randomly allocated to 6 weeks of treatment either with corticosteroid injections (53) or physiotherapy (56).
                Outcome assessments were carried out 3, 7, 13, 26, and 52 weeks after randomisation; some of the assessments were done by an observer blind to treatment allocation. Primary outcome measures were the success of treatment as measured by scores on scales measuring improvement in the main complaint and pain, and improvement in scores on a scale measuring shoulder disability.
                At 7 weeks 40 (77%) out of 52 patients treated with injections were considered to be treatment successes compared with 26 (46%) out of 56 treated with physiotherapy (difference between groups 31%, 95% confidence interval 14% to 48%). The difference in improvement favoured those treated with corticosteroids in nearly all outcome measures; these differences were statistically significant. At 26 and 52 weeks differences between the groups were comparatively small. Adverse reactions were generally mild. However, among women receiving treatment with corticosteroids adverse reactions were more troublesome: facial flushing was reported by 9 women and irregular menstrual bleeding by 6, 2 of whom were postmenopausal.
                The beneficial effects of corticosteroid injections administered by general practitioners for treatment of painful stiff shoulder are superior to those of physiotherapy. The differences between the intervention groups were mainly the result of the comparatively faster relief of symptoms that occurred in patients treated with injections. Adverse reactions were generally mild but doctors should be aware of the potential side effects of injections of triamcinolone, particularly in women. A randomized study of two types of conservative treatment of 78 shoulders in 78 patients with rotator cuff tears was performed. Twenty-five milligrams of sodium hyaluronate (SH) was injected into shoulders in one group (SH group) and 2 mg of dexamethasone was injected in the other group (steroid group). Injection of each drug was planned for once per week for 5 consecutive weeks. In the SH group, University of California at Los Angeles score before treatment was 13.6 +/- 2.6 points in 16 patients who did not require surgery (satisfied patients) and 12.8 +/- 3.5 points in 22 patients who required surgery (unsatisfied patients) (not statistically significant). In the steroid group, University of California at Los Angeles score before treatment was 11.9 +/- 3.6 points for 15 satisfied patients and 12.6 +/- 3.9 points for 25 unsatisfied patients (again, not statistically significant). In the SH group, the score at 4 weeks after treatment for satisfied patients increased to 27.6 +/- 3.1 points, whereas that for unsatisfied patients was 14.9 +/- 1.2 points (P <.0001). Similarly, in the steroid group, the score at 4 weeks after the treatment for satisfied patients increased to 26.5 +/- 2.0 points, whereas that for unsatisfied patients was 15.0 +/- 4.0 points (P <.0001). At 24 weeks after treatment, the score for satisfied patients was 26.2 +/- 3.1 points in the SH group and 25.3 +/- 2.5 points in the steroid group. The effective rate of the SH group was 39.5% and that of the steroid group was 35%. Therapeutic efficacy in the SH group was equivalent to that in the steroid group. In both groups, the rate of patients who engaged in manual labor was significantly higher in the group of unsatisfied patients than in that of satisfied patients. No adverse reaction to either treatment was observed. These results suggest that SH is an effective conservative treatment for patients with rotator cuff tears. Cost effective treatment is needed for common self limiting rheumatological conditions. Periarthritis of the shoulder is an example. There is no consensus for one type of treatment, though local steroids or physiotherapy are conventionally used. Their cost and efficacy were compared in a prospective randomised observer-blind trial--in essence a medical audit of the treatment of a common rheumatological problem. Sixty two consecutive patients presenting with a painful stiff shoulder were studied. Patients with coexistent diseases like cervical spondylosis or a stroke were excluded. They were randomly allocated to receive local steroids, six weeks' physiotherapy, or both. The three groups were of similar age, sex, and disease severity. Assessments of pain and shoulder movement were made initially, at six weeks, and at six months by a 'blinded' observer. Physiotherapy was given by one therapist and injections by one physician. All three groups showed significant improvements by six weeks, with further improvement at six months. Improvements were identical in all three groups. No treatment gave complications. The costs of treatment varied: an injection of triamcinolone cost 2.10 pounds; a six week course of physiotherapy cost 48.50 pounds; combination treatment cost 50.60 pounds. Patients expect treatment for a painful stiff shoulder. The results show that local steroid injections are as effective as physiotherapy alone or a combination. They provide rapid treatment and are less expensive. In the uncomplicated case a local steroid injection is the most cost effective treatment. Forty-eight patients with frozen shoulder for less than six months were assigned at random to receive three shoulder injections into the subacromial bursa or glenohumeral joint at weekly intervals. The treatment groups were (1) intra-articular methylprednisolone and lidocaine, (2) intrabursal methylprednisolone and lidocaine, (3) intra-articular lidocaine, (4) intrabursal lidocaine. The same physical therapy program was carried out for all patients. Assessments of pain and range of motion were performed by a physical therapist who was uninformed about the nature of the injection therapy. There was no significant difference in outcome between intrabursal injection and intra-articular injection. Injection of steroid with lidocaine had no advantage over lidocaine alone in restoring shoulder motion, but partial, transient pain relief occurred in two thirds of the steroid-treated patients. To study the effect of manipulating a shoulder with adhesive capsulitis (frozen shoulder) under anesthesia with and without corticosteroid injection.
                Randomized trial.
                Hospital.
                Twenty-four patients referred for manipulation of a frozen shoulder.
                The patients were randomized into 2 groups. One group received an injection of corticosteroid and manipulation; the other was only administered manipulation during anesthesia.
                The degree of shoulder mobility and pain before and after the manipulation.
                Manipulation under anesthesia increased the mobility of the affected shoulder. Injection with lidocaine and betamethason did not enhance the effect of the manipulation.
                Manipulation under anesthesia without intraarticular corticosteroids is recommended as the therapy for frozen shoulder. Fifty patients with impingement syndrome refractory to long-term conservative treatment were randomized to three treatment groups. All patients received an injection of 10 ml 0.5% bupivacaine, in group 1 without corticosteroid, in group 2 with crystalline corticosteroid and in group 3 with lipoid corticosteroid. Treatment in group 1 had to be stopped because of inefficacy. In groups 2 and 3 favorable results were achieved in 19 out of 40 patients. nan Fifty-five patients with shoulder pain due to rotator cuff tendinitis of less than 12 weeks' duration were randomized to receive either 40 mg methylprednisolone and lignocaine or lignocaine alone. No statistically significant difference could be discerned between the two groups during 12 weeks of follow-up. A prospective, randomized, controlled, double-blind clinical study was performed to determine the short-term efficacy of subacromial injection of corticosteroids for the treatment of subacromial impingement syndrome. Forty patients were randomized to receive either six milliliters of 1 per cent lidocaine without epinephrine (the control group) or two milliliters containing forty milligrams of triamcinolone acetonide per milliliter with four milliliters of 1 per cent lidocaine without epinephrine (the corticosteroid group). The patients were re-examined serially until completion of the study. Nineteen patients, whose mean age was fifty-six years (range, thirty-two to eighty years), were randomized to the corticosteroid group, and twenty-one patients, whose mean age was fifty-seven years (range, thirty-two to eighty-one years), were randomized to the control group. The mean duration of symptoms before the injection was eight months for both groups. Eighteen patients in the corticosteroid group and nineteen patients in the control group had moderate or severe pain before the injection. At the most recent follow-up evaluation, at a mean of thirty-three weeks for the corticosteroid group and twenty-eight weeks for the control group, three patients in the corticosteroid group had moderate or severe pain, compared with fifteen patients in the control group. The mean active range of forward elevation and external rotation improved by 24 and 11 degrees, respectively, for the corticosteroid group and by 10 and 5 degrees, respectively, for the control group. We concluded that subacromial injection of corticosteroids is an effective short-term therapy for the treatment of symptomatic subacromial impingement syndrome. The use of such injections can substantially decrease pain and increase the range of motion of the shoulder. Forty-two patients with frozen shoulder were followed up closely for eight months. They were all taught pendular exercises and randomly allocated to one of four treatment groups: (a) intraarticular steroids, (b) mobilisations , (c) ice therapy, (d) no treatment. This study has shown that there is little long-term advantage in any of the treatment regimens but that steroid injections may benefit pain and range of movement in the early stages of the condition.
Despite many RCTs of corticosteroid injections for shoulder pain, their small sample sizes, variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment. Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained. 
There is a need for further trials investigating the efficacy of corticosteroid injections for shoulder pain. Other important issues that remain to be clarified include whether the accuracy of needle placement, anatomical site, frequency, dose and type of corticosteroid influences efficacy.