Patient Comments: Cortisone Injection - ExperienceCortisone injections make up a very important part of the treatment of steroid injection shoulder review injuries. In combination with an active rehabilitation program they may significantly reduced the need for surgery in shoulder impingement syndrome. Cortisone is a potent anti-inflammatory steroid injection shoulder review. It was only discovered as recently as earning a Nobel Prize for medicine for Hench and his co-workersand has been available in an injectable form since It acts on both acute and chronic phases of inflammation to reduce both tissue swelling and subsequent scar formation. Cortisone injections are useful in the treatment of various musculoskeletal conditions, hormonal injections those of acute inflammation such as acute dianabol and testosterone cycle for beginnersand degenerative joint and tendon conditions. Cortisone injections should only be performed in the setting of an appropriate diagnosis based on taking an accurate history, performing a clinical examination and commonly performing investigations.
Corticosteroid injections for shoulder pain | Cochrane
There are no systematic reviews of corticosteroids for shoulder pain that calculate the numbers needed to treat. We wished to determine the effectiveness in terms of improvement of symptoms of intra-articular and subacromial injections of corticosteroid for rotator cuff tendonitis and frozen shoulder. Systematic review and meta-analysis of randomised controlled trials.
The review methods required any randomised controlled trial in which the effectiveness of subacromial or intra-articular steroid injections versus placebo and versus non-steroidal anti-inflammatory medication, could be ascertained. The outcome was improvement of symptoms. The data abstraction was done independently, as was the validity assessment.
The data was pooled using Review Manager 4. Seven studies were reviewed for corticosteroids versus placebo and three for corticosteroids versus non-steroidal anti-inflammatory drugs NSAIDs. The relative risk for improvement for subacromial corticosteroid injection for rotator cuff tendonitis was 3. The number needed to treat based on the pooled relative risk was 3. The relative risk for high dose 50 mg of prednisone or more was 5.
The relative risks for intra-articular steroid injection for rotator cuff tendonitis were not statistically significant. Subacromial injections of corticosteroids are effective for improvement for rotator cuff tendonitis up to a 9-month period.
Higher doses may be better than lower doses for subacromial corticosteroid injection for rotator cuff tendonitis. Shoulder pain is a common source of distress.
In two cross-sectional surveys based on patients registered with general practices a prevalence of Six previous reviews of the use of corticosteroid injections in shoulders have found conflicting results. A Cochrane review found that subacromial steroid injection was effective in improving range of abduction.
The fifth review was conducted by the same authors as the Cochrane review. This view has some support in the literature. They also concluded that subacromial steroids were no better than non-steroidal anti-inflammatory drugs NSAIDs. Our objective was to systematically review the literature and statistically pool the results of improvement outcomes.
The clinical question was whether or not intra-articular and subacromial injections of corticosteroid are effective compared with placebo and NSAIDs in terms of improvement of symptoms of rotator cuff tendonitis and frozen shoulder. We also wished to calculate a number needed to treat, as this has not been done before.
Authors of studies retrieved and included were contacted regarding any known unpublished work. The reference lists of retrieved papers were also searched for relevant papers. The selection criteria required that the studies be randomised controlled trials in which the effectiveness of corticosteroids could be assessed.
This included studies of corticosteroids versus placebo or NSAIDs, and studies of local anaesthetic and corticosteroids versus local anaesthetic. The participants needed to have a diagnosis of frozen shoulder or rotator cuff tendonitis of any duration. The outcome needed to include improvement, as this was considered the most significant patient-oriented outcome. Independent assessment of included papers was undertaken and any disagreements resolved by consensus.
A validity assessment was conducted using the items from the Pedro scoring system Table 1. Data extraction was also done independently and disagreement resolved through discussion. Data were analysed using Review Manager 4. For improvement we calculated the relative risk and the number needed to treat.
A fixed effects model was used throughout, as there was no significant heterogeneity. A high quality study was one with a Jadad score of three or more. The conduct of this review was undertaken according to the Quorom statement.
We wished to determine the effectiveness in terms of improvement of symptoms of intra-articular and subacromial injections of corticosteroids for rotator cuff tendonitis and frozen shoulder.
A systematic review and meta-analysis of randomised controlled trials indicates that subacromial injections of corticosteroids are effective for improvement of rotator cuff tendonitis up to a 9-month period. They are also probably more effective than non-steroidal anti-inflammatory drugs. There were five studies that had data on improvement for subacromial injections versus placebo for rotator cuff tendonitis Table 2.
There was a significant improvement, with a relative risk of 3. The numbers needed to treat for the statistically significant studies were between 1. The numbers needed to treat obtained from the pooled relative risk using a control event rate of There were no important harms other than transient redness and discomfort.
None of the studies reported tendon rupture. Pooling of the three high dose also the high quality studies had a relative risk of 5. A sensitivity analysis was conducted with the study by Blair et al 17 removed as the outcomes for the corticosteroid group were assessed on average at 33 weeks while the placebo group was assessed at 28 weeks.
The pooled relative risk was similar to that with Blair et al included. There was only one study for intra-articular corticosteroid injection and the effect was not significant. A funnel plot revealed a possible absence of small trials with small effects. All of the clinicians giving the injections were rheumatologists, orthopaedic surgeons, internal medicine specialists or rehabilitation specialists.
There was no difference between these groups. Our results show a significant benefit for subacromial corticosteroid injections versus placebo for painful shoulder. This is the first review to show a benefit for steroid injections in terms of the dichotomous variable improvement. The numbers needed to treat range between 1. The numbers needed to treat in similar ranges were obtained by applying the pooled relative risk to the control event rates.
It is also the first review to suggest that higher doses of corticosteroids may give greater improvement. The interpretation of the subgroups of higher doses requires caution as there was a range of doses and episode duration in the three studies. It is probably not possible in a series of clinical trials to identify safety issues such as tendon rupture.
One reviewer claims that corticosteroid injections into the rotator cuff have not been shown to be deleterious but that it is logical to limit the number of local corticosteroid injections. However, this interpretation is based on two high quality studies, although only one was statistically significant. We could find no steroids versus placebo studies for adhesive capsulitis.
A limitation of this review is possible publication bias, in that by missing unpublished or negative trials we may have overestimated the beneficial effect of subacromial corticosteroid injections. An analysis leaving out the one study from a non-English speaking country did not alter the findings. However, we are confident that most research in this field was identified by our comprehensive, systematic search strategy including hand searching and author contacts.
All of the studies were conducted in outpatient settings and hence our findings are generalisable to those settings. Our findings differ from the other reviews in that we report improvement. They did not pool the papers by Blair et al , 17 Plafki et al 20 and Vecchio et al 21 in part because they did not have sufficient data to analyse for continuous data.
We feel their omission of these papers is not warranted as they contain discrete data that are relevant to effectiveness and possibly more pertinent as they enable a number needed to treat to be calculated. The reviews by McQuay et al , 4 Goupille and Sibilia 6 and van der Heijden et al 5 commented on the poor quality of the literature and did not attempt to pool their findings.
From our data the duration of benefit of subacromial corticosteroid injections appears to be from 3 to 38 weeks. The longer term benefit may not be so enduring, since a 2-year follow-up study of an effective in the short-term corticosteroid injection found no long-term difference between manipulation and physiotherapy, and that up to half of the patients experienced recurrent complaints.
In summary, our findings suggest that subacromial injections of corticosteroids are probably effective in rotator cuff tendonitis. There is insufficient evidence to determine the effectiveness of intra-articular injections for rotator cuff tendonitis or for frozen shoulder. Our finding that using improvement as an outcome rather than pain or range of motion was significant suggests that authors of other musculoskeletal reviews may wish to consider a broader range of outcome measures.
Further research is needed to examine different doses and repeated injections. Outcomes need to include dichotomous results so that numbers needed to treat can be calculated. The small numbers needed to treat may make GPs more likely to use subacromial steroids for rotator cuff syndrome as it is a relatively easy procedure to perform.
Additional information accompanies this article at http: National Center for Biotechnology Information , U. Br J Gen Pract. See " Corticosteroid injections: This article has been cited by other articles in PMC. Abstract Background There are no systematic reviews of corticosteroids for shoulder pain that calculate the numbers needed to treat. Aim We wished to determine the effectiveness in terms of improvement of symptoms of intra-articular and subacromial injections of corticosteroid for rotator cuff tendonitis and frozen shoulder.
Design of study Systematic review and meta-analysis of randomised controlled trials. Results Seven studies were reviewed for corticosteroids versus placebo and three for corticosteroids versus non-steroidal anti-inflammatory drugs NSAIDs. Conclusion Subacromial injections of corticosteroids are effective for improvement for rotator cuff tendonitis up to a 9-month period. Open in a separate window. Was the study described as randomised?
Was the study described as double blind? Was there a description of withdrawals and dropouts? Give 1 extra point if randomisation or blinding appropriate. Deduct 1 point if randomisation or blinding inappropriate. How this fits in There are no systematic reviews of corticosteroids for shoulder pain that calculate the numbers needed to treat. Process of inclusion of studies and usable information.
Table 2 Improvement for subacromial steroid for rotator cuff tendonitis.