Comparative Efficacy of Intra-Articular Steroid Injection and Distension in Patients With Frozen Shoulder: A Systematic Review and Network Meta-Analysis

Abstract

ObjectiveTo compare the efficacy of intra-articular (IA) steroid injection and distension in patients with frozen shoulder. Data SourcesDatabases, including MEDLINE (via PubMed), Embase, Scopus, and Cochrane Library, were searched for studies published up to November 2016. Study SelectionWe included all published randomized controlled trials (RCTs), quasi-experimental studies, and observational studies investigating the effectiveness of IA steroid injection, distension, and physiotherapy in patients with frozen shoulder. Sixteen RCTs and 1 observational study were enrolled in meta-analysis. Data ExtractionFull texts were independently reviewed, and quality of RCTs was assessed with The Cochrane Collaboration's tool. The primary outcome was functional improvement; the secondary outcomes included pain reduction and external rotation (ER) improvement. Data SynthesisIn pairwise meta-analysis, pooled standardized mean difference (SMD) of functional improvement and pain reduction revealed equal efficacy at 3 follow-up time points. With respect to ER improvement, distension has a superior effect compared with IA steroid injection in the short term [(2–4wk; SMD, −.36; 95% confidence interval [CI], −.68 to −.04) and medium term (6–16wk; SMD, −0.80; 95% CI, −1.32 to −0.29). The network meta-analysis indicated a better efficacy for distension than for IA steroid injection in ER improvement only in the medium term (6–16wk; SMD, −0.70; 95% CI, −1.19 to −0.21). ConclusionsIA steroid injection was as effective as distension in shoulder function improvement, pain reduction, and increasing ER of the shoulder. Distension yielded better ER improvement in the medium term but to a minor extent in the long term. For patients with predominant ER limitation, early distension could be considered the primary choice of treatment.