Comparative outcomes of combined corticosteroid with low volume compared to high volume of local anesthetic in subacromial injection for impingement syndrome: systematic review and meta-analysis of RCTs
- 128 Downloads
Subacromial impingement syndrome (SIS) is one of the most frequent pathologies of the shoulder, which may cause serious restriction of daily activities and lifestyle changes. Corticosteroid injection (CI) into the subacromial space is a palliative treatment option. Currently, there have been no studies that compare between the different volumes of CI injection. We have conducted a systematic review and meta-analysis to answer our specific study questions: Are high volume (< 5 ml) better than low volume (≥ 5 ml) of CI injection with respect to pain reduction? This systematic review was conducted according to the preferred reporting items for systematic reviews and meta-analyses guidelines. Relevant studies were identified from Medline and Scopus from inception to May 11, 2017 that reported American shoulder and elbow surgeons (ASES) function score, pain visual analog score (VAS), and postoperative complications of either group. Fifteen studies were included for the analysis of high volume (more than or equal 5 ml), and 5 studies were included for analysis of low volume (less than 5 ml). Overall, there were 1101 patients (732 in the high-volume group and 369 in the low-volume group). A pooling of mean VAS and ASES function score was (N = 557) 2.02 (95% CI 1.52, 2.53), (N = 190) 82.59 (95% CI 76.92, 88.27) in high-volume group and (N = 179) 2.60 (95% CI 1.94, 3.26), (N = 95) 84.65 (95% CI 81.64, 86.82) in low-volume group, respectively. The unstandardized mean difference of ASES and VAS of high volume was − 0.58 (95% confidence interval (CI): − 1.38, 0.22) and − 2.06 (95% CI − 8.35, 4.23) scores lower than low-volume CI in SIS patients, but without statistical significance. A total of 11 studies in the high-volume group and 4 studies in the low-volume group reported adverse effects. The total complication rate per patient was 6.2% (2.3, 10.1%) in the high-volume group and 11.7% (0.3, 12%) in the low-volume group (p = 0.091). No significant differences were noted for complications. In subacromial impingement syndrome, the corticosteroid injection had acceptable pain and functional outcomes. Higher volume had a lower ASES, VAS, and risk of having complication when compared to lower volume. However, there are no statistically significant differences between groups. Larger, randomized noninferiority or equivalent trial studies are needed to confirm these findings as the current literature is still insufficient.
Level of evidence I.
KeywordsSubacromial impingement syndrome SIS Corticosteroid injection Different volume VAS
All authors declare no funding source or sponsor involvement in the study design, collection, analysis, and interpretation of the data, in writing the manuscript, and in submission of the manuscript for publication.
This study has no funding support.
Compliance with ethical standards
Conflict of interest
All authors declare that they have no conflicts of interests.
This article does not contain any studies with human participants performed by any of the authors.
- 4.Chang KV, Hung CY, Wu WT, Han DS, Yang RS, Lin CP (2016) Comparison of the effectiveness of suprascapular nerve block with physical therapy, placebo, and intra-articular injection in management of chronic shoulder pain: a meta-analysis of randomized controlled trials. Arch Phys Med Rehabil 97(8):1366–1380. doi: 10.1016/j.apmr.2015.11.009 CrossRefPubMedGoogle Scholar
- 5.Dietrich TJ, Peterson CK, Brunner F, Hodler J, Puskas GJ, Pfirrmann CWA (2013) Imaging-guided subacromial therapeutic injections: prospective study comparing abnormalities on conventional radiography with patient outcomes. Am J Roentgenol 201(4):865–871. doi: 10.2214/AJR.12.10094 CrossRefGoogle Scholar
- 6.Dogu B, Yucel SD, Sag SY, Bankaoglu M, Kuran B (2012) Blind or ultrasound-guided corticosteroid injections and short-term response in subacromial impingement syndrome: a randomized, double-blind, prospective study. Am J Phys Med Rehabil 91(8):658–665. doi: 10.1097/PHM.0b013e318255978a CrossRefPubMedGoogle Scholar
- 8.Foye PM, Sullivan WJ, Panagos A, Zuhosky JP, Sable AW, Irwin RW (2007) Industrial medicine and acute musculoskeletal rehabilitation 6 Upper- and lower-limb injections for acute musculoskeletal injuries and injured workers. Arch Phys Med Rehabil 88(3 (Suppl 1)):S29–S33. doi: 10.1016/j.apmr.2006.12.013 CrossRefPubMedGoogle Scholar
- 10.Hay EM, Thomas E, Paterson SM, Dziedzic K, Croft PR (2003) A pragmatic randomised controlled trial of local corticosteroid injection and physiotherapy for the treatment of new episodes of unilateral shoulder pain in primary care. Ann Rheum Dis 62(5):394–399. doi: 10.1136/ard.62.5.394 CrossRefPubMedPubMedCentralGoogle Scholar
- 12.Hong JY, Yoon SH, Moon DJ, Kwack KS, Joen B, Lee HY (2011) Comparison of high-and low-dose corticosteroid in subacromial injection for periarticular shoulder disorder: a randomized, triple-blind, placebo-controlled trial. Arch Phys Med Rehabil 92(12):1951–1960. doi: 10.1016/j.apmr.2011.06.033 CrossRefPubMedGoogle Scholar
- 15.Karthikeyan S, Kwong HT, Upadhyay PK, Parsons N, Drew SJ, Griffin D (2010) A double-blind randomised controlled study comparing subacromial injection of tenoxicam or methylprednisolone in patients with subacromial impingement. J Bone Jt Surg Br 92(1):77–82. doi: 10.1302/0301-620x.92b1.22137 CrossRefGoogle Scholar
- 18.Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Ioannidis JP, Clarke M, Devereaux PJ, Kleijnen J, Moher D (2009) The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS Med 6(7):e1000100CrossRefPubMedPubMedCentralGoogle Scholar
- 22.Min KS, St. Pierre P, Ryan PM, Marchant BG, Wilson CJ, Arrington ED (2013) A double-blind randomized controlled trial comparing the effects of subacromial injection with corticosteroid versus NSAID in patients with shoulder impingement syndrome. J Shoulder Elbow Surg 22(5):595–601. doi: 10.1016/j.jse.2012.08.026 CrossRefPubMedGoogle Scholar
- 27.Rhon DI, Boyles RB, Cleland JA (2014) One-year outcome of subacromial corticosteroid injection compared with manual physical therapy for the management of the unilateral shoulder impingement syndrome: a pragmatic randomized trial. Ann Int Med 161(3):161–169. doi: 10.7326/m13-2199 CrossRefPubMedGoogle Scholar
- 29.Sage W, Pickup L, Smith TO, Denton ERE, Toms AP (2013) The clinical and functional outcomes of ultrasound-guided vs landmark-guided injections for adults with shoulder pathology—a systematic review and meta-analysis. Rheumatology 52(4):743–751. doi: 10.1093/rheumatology/kes302 CrossRefPubMedGoogle Scholar
- 33.StataCorp (2015) Stata statistical software: release 14. StataCorp LP, College StationGoogle Scholar
- 34.Thakkinstian A, McEvoy M, Minelli C, Gibson P, Hancox B, Duffy D, Thompson J, Hall I, Kaufman J, Leung TF, Helms PJ, Hakonarson H, Halpi E, Navon R, Attia J (2005) Systematic review and meta-analysis of the association between β2-adrenoceptor polymorphisms and asthma: a HuGE review. Am J Epidemiol 162(3):201–211. doi: 10.1093/aje/kwi184 CrossRefPubMedGoogle Scholar
- 37.Van Der Sande R, Rinkel WD, Gebremariam L, Hay EM, Koes BW, Huisstede BM (2013) Subacromial impingement syndrome: effectiveness of pharmaceutical interventions-nonsteroidal anti-inflammatory drugs, corticosteroid, or other injections: a systematic review. Arch Phys Med Rehabil 94(5):961–976. doi: 10.1016/j.apmr.2012.11.041 CrossRefPubMedGoogle Scholar
- 38.von Wehren L, Blanke F, Todorov A, Heisterbach P, Sailer J, Majewski M (2016) The effect of subacromial injections of autologous conditioned plasma versus cortisone for the treatment of symptomatic partial rotator cuff tears. Knee Surg Sports Traumatol Arthrosc 24(12):3787–3792. doi: 10.1007/s00167-015-3651-3 CrossRefGoogle Scholar