Glenohumeral Injection Research Articles

The Different Effects of 2 Consecutive Glenohumeral Injections of Corticosteroids on Pain Reduction and Range-of-Motion Improvement in Frozen-Phase Frozen Shoulder

PurposeThe purpose of the study is to investigate the improvement of frozen phase frozen shoulder (FS) patients’ pain and shoulder mobility, including passive forward elevation (FE), external rotation (ER), and internal rotation (IR) following two consecutive intra-articular corticosteroids (IACS) injections. MethodsThis retrospective cohort study was performed from July 2020 to November 2023. All patients with frozen phase FS received two ultrasound-guided IACS injections at a six-week intervals. FE, ER, IR, and visual analog scale (VAS) were measured at each follow-up consultation with a 6-week interval. ResultsA total of 134 patients finished the study. There were varying degrees of change in pain relief and ROM improvement between each IACS injection. The FE and IR improved significantly between the first and second injections (both P < 0.001), while ER only improved significantly after the second injection (P < 0.05). The pain level improved both after the first and second injections (both P < 0.001). ConclusionPatients with frozen-phase FS demonstrated improved pain and mobility of FE and IR after a single IACS injection. However, a second IACS injection provides similar therapeutic effects and also significantly improves ER mobility.

Effects of Intra-Articular Triamcinolone Injection on Adhesive Capsulitis after Breast Cancer Surgery.

To investigate the effects of intra-articular glenohumeral joint triamcinolone injection in treating secondary adhesive capsulitis after breast cancer surgery. This study prospectively enrolled 37 participants, including 22 in the breast cancer surgery group and 15 in the idiopathic group. All participants received intra-articular glenohumeral joint triamcinolone injection in the affected shoulder joint. The clinical outcomes included the Shoulder Pain and Disability Index (SPADI), passive range of motion (PROM), and pain intensity on the Numeric Rating Scale (NRS), which were evaluated before the intervention and 1, 3, and 6 months after. The primary outcome of this study was the mean difference in the total SPADI from baseline to 6 months after the intervention. The mean differences in the total SPADI scores from baseline to 6 months after the intervention were 36.2 ± 16.4 and 47.9 ± 15.2 in the breast cancer surgery group and the idiopathic group, respectively. There was no significant difference between the two groups (p = 0.1495). However, the improvements in the SPADI pain subscale at the 3- and 6-month follow-up visits (-31.2 vs. -48.8, p = 0.042; -34.1 vs. -50.7, p = 0.0006) and the PROM of abduction at the 3-month follow-up (52.4 vs. 70.3, p = 0.0072) were inferior in the breast cancer surgery group compared to the idiopathic group. There were no adverse events in either group. Intra-articular triamcinolone injection is an effective and safe treatment option for adhesive capsulitis after breast cancer surgery; however, it has less effect than for idiopathic adhesive capsulitis.

Targeting the Sweet Spot: A Systematic Review With Meta-Analysis of Anterior Versus Posterior Glenohumeral Joint Injections for Adhesive Capsulitis.

To compare clinical outcomes following steroid injections using the anterior and posterior approaches. Systematic review with meta-analysis. Embase, Web of Science, and Cochrane Center Register of Controlled Trials were searched for randomized control trials (RCTs) and prospective comparative studies. Patients with adhesive capsulitis. Glenohumeral steroid injections using either anterior or posterior approach. Pain visual analog scale (VAS) and shoulder range of motion (ROM) at 12 weeks, accuracy, and adverse events. Standardized mean difference (SMD) for VAS and weighted mean difference (WMD) for ROMs. We identified 6 RCTs and one prospective comparative study with a total of 468 patients. While there was no difference in pain VAS at 12 weeks between the 2 approaches (SMD, -0.86; 95% CI, -1.76 to 0.04), the anterior approach resulted in greater improvements in external rotation (WMD, 8.08; 95% CI, 0.79-15.38) and abduction (WMD, 6.76; 95% CI, 3.05-10.48) compared with the posterior approach. Subgroup analysis with RCTs that utilized steroid injection with hydrodilatation for both approaches demonstrated greater reduction in pain VAS at 12 weeks with the anterior approach (SMD, -0.52; 95% CI, -0.98 to -0.07). Overall, procedures were well tolerated without major complications. While pain reduction is similar, the anterior approach may be more beneficial in restoring shoulder external rotation and abduction compared with the posterior approach at 12 weeks. Steroid injection combined with hydrodilatation may further improve pain control when performed with the anterior approach at 12 weeks.

Outcomes of ultrasound-guided injections of Bennett lesions of the shoulder.

To describe our technique and short term follow up of ultrasound-guided injections of symptomatic Bennett lesions. We performed 13 ultrasound-guided injections in 10 baseball players from August 2014 to August 2021. The cohort was comprised of 10 males, with a mean age of 25years and 1month (age range: 17years, 10months-33years, 1month). Of the 10 patients, 6 were major league baseball players (including 5 pitchers and a second baseman), 3 were minor league baseball pitchers; and 1 pitched in high school. Symptoms in our patients included posterior shoulder pain at rest, pain with pitching (including in the acceleration phase and with follow-through), glenoid internal reduction deficit, and decreased pitching velocity. The procedure was performed in a similar fashion as a standard posterior approach glenohumeral injection, though with the linear transducer positioned slightly more medially. The needle was inserted from a lateral to medial approach, in plane with the transducer and aimed to the superficial surface of the Bennett lesion, onto which anesthetic and steroid was injected, avoiding injection into the glenohumeral joint. All patients had MRIs that showed Bennett lesions and all but one of the sonograms demonstrated the Bennett lesion. In 8/12 (67%) injections, the patient reported varying degrees of immediate symptom relief. In 4/12 injections, patients were unable to assess for immediate postprocedural change in symptomatology and for one patient post-procedural symptomatology was not documented. No complications occurred. Analytics of the average 4-seam fastball velocity was availablefor 2 of the major league players who had in-season injections, with minimal change in postprocedural velocity in the year after their ultrasound procedure; for one of the pitchers, his fastball velocity slightly increased in the month after the procedure while the other pitcher had his injection towards the end of the season and he threw no fastballs in his final games of the season. Two of the other professional pitchers went on to surgical intervention and neither returned to pitch professionally. Injection of symptomaticBennettlesions is a safe procedure and can provide symptomatic relief that may be temporary, though equivocally useful clinically.

High accuracy of intra-articular needle position during anterior landmark guided glenohumeral injections

ObjectivesImage-guided ultrasound or fluoroscopic glenohumeral injections have high accuracy rates but require training, equipment, cost, and radiation exposure (fluoroscopy). In contrast, landmark-guided glenohumeral injections do not require additional subspecialist referrals or equipment. An optimal technique would be safe and accurate and have few barriers to implementation. The purpose of this study was to define the accuracy of glenohumeral needle placement via an anterior landmark-guided approach as assessed by direct arthroscopic visualization. MethodsA consecutive series of adult patients undergoing shoulder arthroscopy in the beach chair position were included in this study. Demographic and procedural data were collected. The time required to perform the injection, the precise location of the needle tip, and factors that affected the accuracy of the injection were also assessed. ResultsA standardized anterior landmark-guided glenohumeral joint injection was performed in the operating room prior to surgery, and the location of the needle tip was documented by arthroscopic visualization with a low complication profile and few barriers to implementation. A total of 81 patients were enrolled. Successful intra-articular glenohumeral needle placement by sports medicine and shoulder/elbow fellowship-trained orthopedic surgeons was confirmed in 93.8% (76/81) of patients. The average time to complete the procedure was 24.8 ​s. There were no patient-related variables associated with nonintra-articular injections in the cohort. ConclusionsThis study demonstrated that the technique of anterior landmark-guided glenohumeral injection has an accuracy of 93.8% and requires less than 30 ​s to perform. This method is safe, yields similar accuracy to image-guided procedures, has improved cost and time efficiency, and requires less radiation exposure. No patient-related factors were associated with inaccurate needle placement. Anterior landmark-guided glenohumeral injections may be utilized with confidence by providers in the clinical setting. Level of EvidenceLevel 5.IRB: Approved under Stanford IRB-56323.

Glenohumeral versus subacromial steroid injections for impingement syndrome with mild stiffness: a randomized controlled trial.

The subacromial (SA) space is a commonly used injection site for treatment of impingement syndrome. For shoulder stiffness, glenohumeral (GH) injections are commonly performed. However, in cases of impingement syndrome with mild shoulder stiffness, the optimal site of steroid injection has yet to be identified. This prospective, randomized study compared the short-term outcomes of ultrasound-guided GH and SA steroid injections in patients who were diagnosed with impingement syndrome and mild stiffness. Each group comprised 24 patients who received either a GH or SA injection of 40 mg of triamcinolone. Range of motion and clinical scores were assessed before and 3, 7, and 13 weeks after the injection. GH and SA injections significantly improved the range of motion and clinical scores after 13 weeks of follow-up. Notably, targeting the GH joint resulted in an earlier gain of forward elevation, external rotation, and internal rotation in 3 weeks (P<0.001, P=0.012, and P=0.002, respectively) and of internal rotation and a Constant-Murley score in 7 weeks (P<0.001 and P=0.046). Subsequent measurements were similar between the groups and showed a steady improvement in all ranges of motion and clinical scores. GH injections may be more favorable than SA injections for treatment of impingement syndrome with mild stiffness, especially in improving the range of motion in the early period. However, the procedures showed similar outcomes after 3 months. Level of evidence: I.

Multisite Injection of Corticosteroids is more Efficient than a Single Glenohumeral Injection in Treating Acute Frozen Shoulder

Objective: To compare the effectiveness of a single glenohumeral injection versus multisite injection of corticosteroids in treating acute frozen shoulder. Study design: Randomized controlled trial Setting and duration: Department of Orthopedic Surgery Civil Hospital Bahawalpur from January 2022 to December 2022. Material and methods: Total 74 patients with acute frozen shoulder having onset of symptoms within the last 12 months were included. This study compared the functional ratings, Mobility, and pain alleviation of patients with primary Frozen Shoulder (FS) after different period of follow up in our OPD. In multisite group, triamcinolone acetonide, bupivacaine and saline were injected into four different sites. In the single glenohumeral injection group, only the glenohumeral joint was injected. Both groups received physiotherapy after injection, including soft tissue therapy, joint mobilization and a home exercise program. The outcome measures were assessed through Range of motion, function and pain scores at a follow up of every three months, six months and then after one year. Results: According to the study, the patients receiving injections at multisite outperformed those receiving single-injection on the visual analogue scale (VAS) at all follow-up intervals (P = 0.01). Moreover, compared to the single-injection group, the multisite-injection group had substantially superior active and passive ROM restoration (P 0.05) and higher functional scores (P 0.05). Practical Implication: It suggests multisite injections as a treatment for frozen shoulder, in contrast to prior studies. Positive characteristics of the study include the use of a blinded clinical examination and the presence of a sufficient number of participants Conclusion: In conclusion, multisite injection of corticosteroids has more potency than a single injection in reducing pain in patients with acute frozen shoulder. Clinicians may consider multisite injection as a preferred method of treatment for primary frozen shoulder, especially in patients with severe pain. Keywords: multisite injection, frozen shoulder, glenohumeral injection, pain, stiffness

Ultrasound-Guided Glenohumeral Corticosteroid Injection for the Treatment of Adhesive Capsulitis of the Shoulder: The Role of Clinical Stage in Response to Treatment.

Treatment for idiopathic adhesive capsulitis of the shoulder remains controversial. Stages 1 to 2 reflect an inflammatory process supporting a rationale for intra-articular glenohumeral joint corticosteroid injection to treat synovial inflammation and prevent progression to capsular fibrosis. We hypothesize that an intra-articular ultrasound-guided glenohumeral injection (USGI) of corticosteroid in patients diagnosed with Stage 1 or 2 idiopathic adhesive capsulitis will result in timely functional recovery and resolution of pain and stiffness. Case series. Level 4. Patients with Stage 1 or 2 idiopathic adhesive capsulitis treated with an intra-articular corticosteroid injection were included. Patients were seen by a single physician and diagnosed using history and physical examination with careful attention to measurement of glenohumeral range of motion (ROM). A total of 61 patients met inclusion criteria. ROM measurements documented in the patient charts were recorded in forward flexion, abduction, internal rotation, and external rotation in neutral abduction. All ROM measurements were performed pre- and postinjection. All patients were treated with an USGI of local anesthetic and depomedrol. Recovery criteria were defined as forward flexion, abduction, and external rotation within 15° of the contralateral side and internal rotation within 3 spinous process levels of the contralateral side. A total of 11 patients with Stage 1 and 50 patients with Stage 2 adhesive capsulitis comprised the final study cohort. Within the Stage 1 cohort, all 11 patients met recovery criteria for forward flexion and internal rotation (100%), 10 met recovery criteria for abduction (91%), and 8 met recovery criteria for external rotation (73%). Within the Stage 2 cohort, 31 patients met recovery criteria for forward flexion (62%), 30 met recovery criteria for abduction (60%), 36 met recovery criteria for internal rotation (72%), and 25 met recovery criteria for external rotation (50%). The difference in time to recovery in days was statistically significant in all ROM planes and was within 2 to 6 weeks for patients in Stage 1 and 7 to 10 weeks for Stage 2. USGI for early adhesive capsulitis allows patients to recover ROM more rapidly if performed early after onset of pain and stiffness. These results stress the importance of recognition of idiopathic adhesive capsulitis in its early stages and subsequent intervention with an intra-articular glenohumeral corticosteroid injection.

A randomized clinical trial of glenohumeral joint steroid injection versus suprascapular nerve block in patients with frozen shoulder: a protocol for the Therapeutic Injections For Frozen Shoulder (TIFFS) study.

Frozen shoulder is a common, painful condition that results in impairment of function. Corticosteroid injections are commonly used for frozen shoulder and can be given as glenohumeral joint (GHJ) injection or suprascapular nerve block (SSNB). Both injection types have been shown to significantly improve shoulder pain and range of motion. It is not currently known which is superior in terms of relieving patients' symptoms. This is the protocol for a randomized clinical trial to investigate the clinical effectiveness of corticosteroid injection given as either a GHJ injection or SSNB. The Therapeutic Injections For Frozen Shoulder (TIFFS) study is a single centre, parallel, two-arm, randomized clinical trial. Participants will be allocated on a 1:1 basis to either a GHJ corticosteroid injection or SSNB. Participants in both trial arms will then receive physiotherapy as normal for frozen shoulder. The primary analysis will compare the Oxford Shoulder Score (OSS) at three months after injection. Secondary outcomes include OSS at six and 12 months, range of shoulder movement at three months, and Numeric Pain Rating Scale, abbreviated Disabilities of Arm, Shoulder and Hand score, and EuroQol five-level five-dimension health index at three months, six months, and one year after injection. A minimum of 40 patients will be recruited to obtain 80% power to detect a minimally important difference of ten points on the OSS between the groups at three months after injection. The study is registered under ClinicalTrials.gov with the identifier NCT04965376. The results of this trial will demonstrate if there is a difference in shoulder pain and function after GHJ injection or SSNB in patients with frozen shoulder. This will help provide effective treatment to patients with frozen shoulder.

Effects of glenohumeral corticosteroid injection on stiffness following arthroscopic rotator cuff repair: a prospective, multicentric, case-control study with 18-month follow-up.

This study aimed to analyze the efficacy of single-dose corticosteroid injection (CSI) administered at 6 weeks postoperative to treat stiffness following arthroscopic rotator cuff repair (ARCR). In this prospective, multicentric, case-control study, post-ARCR stiffness at 6 weeks was treated with either a single dose of intra-articular CSI (CSI group) or physical therapy with oral analgesics (non-CSI group). Pain intensity according to visual analog scale (VAS), functional outcome using the Constant Murley Shoulder Score, time to return to activities of daily living (ADLs), and retear rate were recorded at 6 weeks, 9 weeks, 12 weeks, 6 months, 12 months, and 18 months postoperatively in both groups. A total of 149 patients (54.5%) in the CSI group and 124 patients (45.5%) in the non-CSI group were included in this study. Pain and function were significantly better in the CSI group at 9-week, 12-week, and 6-month (P&lt;0.001) follow-up, whereas they were not significantly different when the groups were compared at 12- and 18-month follow-up. The mean duration to return to ADLs was significantly shorter (P&lt;0.001) in the CSI group. The incidence of retears was not significantly different (P=0.36) between groups at the end of 18 months of follow-up. Single-dose intra-articular CSI administered at 6 weeks postoperative to treat post-ARCR stiffness significantly improved pain, function, and duration of return to ADLs without increasing the risk of retears compared to patients who did not receive intra-articular CSI.

Paper 89: Ultrasound-guided Glenohumeral Corticosteroid Injection for the Treatment of Adhesive Capsulitis of the Shoulder: The Role of Clinical Stage in Response to Treatment

Objectives:The treatment for idiopathic adhesive capsulitis of the shoulder remains controversial. The pathophysiology of adhesive capsulitis supports the rationale for intra-articular glenohumeral joint corticosteroid injection to treat the synovial inflammation in stages 1 and 2, that results in capsular fibrosis in the later stages of adhesive capsulitis. We hypothesize that an intra-articular ultrasound-guided glenohumeral injection (USGI) of corticosteroid in patients diagnosed with stage 1 or stage 2 idiopathic adhesive capsulitis will result in timely functional recovery and resolution of pain and stiffness.Methods:This is a retrospective analysis of a cohort of patients with stage 1 or stage 2 idiopathic adhesive capsulitis, diagnosed using history and physical examination. A total of 61 patients met inclusion criteria. Range of motion (ROM) measurements documented in the patient charts were recorded in four planes: forward flexion, abduction, internal rotation, and external rotation in neutral abduction. All ROM measurements were performed pre-injection and at all subsequent post-injection visits by a single treating physician. All patients were treated with an ultrasound-guided intra-articular injection of local anesthetic and depomedrol. Recovery criteria were defined as forward flexion, abduction, and external rotation to within 15 degrees of the contralateral side and internal rotation to within three spinous process levels of the contralateral side.Results:A total of 11 patients with Stage 1 and 50 patients with Stage 2 adhesive capsulitis comprised the study cohort. The mean age was 55 years (SD=8, range: 38 to 72) and 49 (80%) patients were female. Within the stage 1 cohort, all 11 patients met recovery criteria for forward flexion (100%), 10 patients met recovery criteria for abduction (91%), 11 patients met recovery criteria for internal rotation (100%), and 8 patients met recovery criteria for external rotation (73%). Within the stage 2 cohort, 31 patients met recovery criteria for forward flexion (62%), 30 patients met recovery criteria for abduction (60%), 36 patients met recovery criteria for internal rotation (72%), and 24 patients met recovery criteria for external rotation (48%). Time to recovery in days for each ROM compared between the stage 1 and stage 2 cohorts was statistically significant in all ROM planes (forward flexion (p<0.0001), abduction (p<0.0001), internal rotation (p=0.0008), and external rotation (p=0.0096)), indicating a greater proportion of stage 1 patients had a shorter time to recovery after injection. Figures 1-4 depict cumulative survival functions between Stage 1 and Stage 2 patients for each individual ROM measurement.Conclusions:USGI for early adhesive capsulitis allows patients to recover ROM more rapidly. Importantly, Stage 1 patients recovered faster than Stage 2 patients in all ROM planes, with only forward flexion reaching statistical significance. This suggests that prompt recognition of early idiopathic adhesive capsulitis and subsequent USGI with corticosteroid and local anesthetic plays an important role in timely recovery of motion and symptom resolution thus shortening the natural history of this disease and preventing the development of significant fibrosis.Figure 1.Cumulative survival functions between Stage 1 and Stage 2 patients for Forward FlexionFigure 2.Cumulative survival functions between Stage 1 and Stage 2 patients for AbductionFigure 3.Cumulative survival functions between Stage 1 and Stage 2 patients for Internal RotationFigure 4.Cumulative survival functions between Stage 1 and Stage 2 patients for External Rotation

Accuracy of shoulder joint injections with ultrasound guidance: Confirmed by magnetic resonance arthrography.

BACKGROUNDIntra-articular glenohumeral joint injections are essential procedures for treating various shoulder disorders. Fluoroscopy-guided injections have been extensively used; however, they pose a risk of radiation exposure and are expensive and time-consuming. Recently, it has been suggested that ultrasound-guided injections are accurate and cost effective procedures.AIMTo evaluate the accuracy of ultrasound-guided glenohumeral injections using a posterior approach that is confirmed using magnetic resonance arthrography (MRA).METHODSThe study included 179 shoulders of patients with recurrent anterior instability (150 patients; 103 and 76 right and left shoulders, respectively; 160 males and 19 females; average age = 20.5 years; age range: 14-63 years) who underwent MRA for preoperative diagnosis. They were injected with 12 mL lidocaine (1%) using the ultrasound-guided posterior approach and then underwent magnetic resonance imaging. Two shoulder surgeons, except for the injector, evaluated the transverse relaxation (T2)-weighted images of axial planes and classified the intra-articular condition of injected contrast into three groups based on one of the three following scenarios: no leakage, injection into the glenohumeral joint without leakage; minor leakage, practical intra-articular injection with some leakage outside the posterior rotator cuffs; and major leakage, inaccurate injection with mass leakage without any contrast into the joint. The inter-rater reliability between two assessors was also evaluated by calculating Cohen’s kappa coefficient. The learning curve was assessed regarding the inaccurate injection rate by analyzing Spearman’s rank correlation coefficient.RESULTSOf the 179 injections, 163 shoulders (91.0%) had no leakage, 10 shoulders (5.6%) had minor leakage, and six shoulders (3.4%) had major leakage. In total, 173 shoulders (96.6%) were intra-articularly injected; thus, we could detect anterior labrum and capsular pathologies. Regarding the inter-rater reliability, the kappa coefficient was 0.925, indicating consistency in the evaluations by both examiners. Regression analysis of the inaccurate injection rate for assessingtechnical learning showed a logarithmic curve with a downward trend (R2 = 0.887, P < 0.001). Three (50%) of the six inaccurate injections classified into “major leakage” were observed in the first 30 injections, indicating that the accurate injection showed a leaning effect.CONCLUSIONUltrasound-guided intra-articular glenohumeral injections using a posterior approach had high accuracy; however, injection accuracy depends on clinical experience.

Does the application of pulse radiofrequency to the suprascapular nerve provide additional benefit in patients who have undergone glenohumeral intra-articular steroid injection and suprascapular nerve block?

Shoulder pain is one of the most common musculoskeletal pain syndromes. Interventional treatments can be applied to patients who do not respond to conservative therapies. Intra-articular steroid injection and suprascapular nerve block are both short-acting and may sometimes be clinically inadequate. In this study, the answer to the question of whether pulse radiofrequency application to the suprascapular nerve provides additional benefit was investigated. Patients who had shoulder pain and were injected between October 2016 and April 2018 were evaluated retrospectively. Totally 160 patients who underwent shoulder injections were included in the study. Patients were divided into two groups: 114 patients who underwent shoulder intra-articular steroid injection and suprascapular nerve block, as Group 1 and 46 patients who underwent pulse radiofrequency to the suprascapular nerve, in addition to shoulder intra-articular steroid injection and suprascapular nerve block, as Group 2. There was no statistical difference between the groups in pre-intervention numerical rating scale (NRS) scores. One month after the intervention, NRS scores of Group 2 were significantly lower than Group 1. In both groups, 1 month after the intervention NRS scores were significantly lower than pre-intervention. The duration of pain relief for Group 2 was longer than Group 1. The satisfaction percentages of patients for Group 2 were higher than Group 1. In addition to glenohumeral intra-articular steroid injection and suprascapular nerve block, pulse radiofrequency application to the suprascapular nerve provides additional benefits in terms of NRS scores, duration of pain relief, and patient satisfaction.

Clinical Fate of Glenohumeral Osteoarthritis Following Intraarticular Corticosteroid Injection: An Analysis in 311 Shoulders.

BackgroundIntraarticular corticosteroid injection is commonly used conservative treatment for glenohumeral osteoarthritis (OA). The purpose of this study was to investigate the clinical fate of symptomatic glenohumeral OA following intraarticular corticosteroid injection and to identify factors associated with undergoing shoulder arthroplasty.MethodsGlenohumeral OA patients who had undergone at least one glenohumeral corticosteroid injection from 2012 to 2017 were identified. Data for demographics, comorbidities, number of injections, severity of radiographic arthritis, and subsequent treatment were collected up to February 2020. Data were analyzed to compare between patients who had eventually undergone shoulder arthroplasty and those who had not.ResultsA total of 311 shoulders (275 patients) were followed up for 3 to 8 years after the index injection. The mean age of patients was 64.7 years. There were 148 females, and 116 shoulders (37.3%) eventually underwent arthroplasty, 68 (21.9%) further injections only, 104 (33.4%) no further treatment, 14 (4.5%) a non-arthroplasty surgical procedure, and 9 (2.9%) were lost to follow up. Severity of radiographic arthritic changes, female sex, younger age, and nonsmoking status were found to be significantly associated with undergoing arthroplasty (p < 0.001, p = 0.014, p = 0.003, and p = 0.043, respectively).ConclusionApproximately one third of glenohumeral OA patients who had received an intraarticular corticosteroid injection eventually elected to undergo shoulder arthroplasty within 3 to 8 years of the injection. High-grade arthritic changes in radiographs, female gender, and younger age were found to be independent factors associated with undergoing arthroplasty. This information may be useful in counseling patients about their future clinical course.Level of Evidence: Level III Retrospective comparative study

The Effect of Glenohumeral Joint Injection Prior to Physical Therapy on Treatment Outcomes in Adhesive Capsulitis

Objective: The objective of this study was to evaluate whether ultrasound-guided intraarticular (IA) glenohumeral injection applied before physical therapy and exercise therapy program (PTETP) contributes to the treatment outcomes in patients with adhesive capsulitis of the shoulder (ACS). Methods: The medical records of 93 patients diagnosed with ACS who underwent the same physical therapy modalities five sessions per week for three weeks (consisted of superficial heating (infrared), transcutaneous electrical nerve stimulation, and therapeutic ultrasound) and exercise therapy program between October 1, 2019–March 1, 2020 were retrospectively evaluated. A total of 41 patients who met inclusion and exclusion criteria were divided into two groups in terms of injection application. Patients who were applied ultrasound guided IA glenohumeral injections before PTETP were considered “injection patients” (n=19), while other patients were considered “non-injection patients” (n=22). The active and passive range of motion (ROM), severity of pain, and degrees of pain and disability of the affected shoulders were assessed at baseline (day 0) and end of PTETP (day 21). Results: Physical therapy modalities and exercise therapy used in ACS treatment had a positive effect on pain scores, ROM, and disability scores at the end of three weeks. It was determined that ultrasound-guided IA injection prior to this treatment the positive effect on daytime and nighttime pain but did not provide additional benefit on ROM or disability. Conclusion:Ultrasound-guided glenohumeral IA injection therapy before PTETP may be beneficial in ACS patients with predominant symptoms of pain.

Immediate Pain Relief at Time of Corticosteroid Injection for Idiopathic Adhesive Capsulitis as a Predictor of Eventual Outcomes.

Background:Corticosteroid injection and physical therapy remain the mainstay of treatment for idiopathic adhesive capsulitis of the shoulder; however, a certain percentage of patients will not improve using these interventions and will require manipulation under anesthesia (MUA) and/or lysis of adhesions (LOA).Purpose:To evaluate whether the immediate pain reduction after fluoroscopic-guided, mixed anesthetic-corticosteroid injection for idiopathic adhesive capsulitis is related to the eventual need for LOA/MUA or a repeat glenohumeral steroid injection.Study Design:Case-control study; Level of evidence, 3.Methods:This single-institution study involved patients undergoing fluoroscopic glenohumeral corticosteroid injection for a diagnosis of idiopathic adhesive capsulitis between 2010 and 2017. Included were patients with a minimum of 1-year postinjection follow-up and visual analog scale (VAS) pain scores from immediately before and after the injection. The primary analysis was the relationship between patients with an immediate change in VAS score after injection and those who underwent LOA/MUA. A repeat glenohumeral injection was also evaluated as an outcome. Receiver operator characteristic curves and a multivariate binomial logistic regression analysis were performed.Results:Overall, 739 shoulders in 728 patients (mean age, 52.6 years; 68% women) were included, of which 38 (5.1%) underwent LOA/MUA and 209 (28%) underwent repeat injections. The immediate change in the VAS score was not significantly associated with the eventual need for LOA/MUA. Preinjection VAS and immediate postinjection VAS scores were not significant predictors of eventual LOA/MUA or subsequent injection. For all 3 predictors, the area under the receiver operator characteristic curve classified them as extremely poor discriminators.Conclusion:The immediate pain response to a fluoroscopic-guided glenohumeral injection for idiopathic shoulder adhesive capsulitis was not predictive of the eventual need for LOA/MUA or subsequent injection. Patients can be counseled that even if their initial pain response to an injection is poor, they still have an excellent chance of avoiding surgery, as the overall rate of LOA/MUA was low (5.1%).

A physiotherapy triage service for orthopaedic upper limb service: an effective way to reduce clinic visits and identify patients for operative intervention.

IntroductionWaiting times for orthopaedic outpatient clinics are steadily increasing over the past number of years worldwide. Physiotherapy triage clinics are being utilised to improve access for patients with non-urgent or routine musculoskeletal disorders, to be seen in a timely manner in specialised out-patient clinics. Using these clinics, the aim is to ultimately stratify patients into appropriate management pathways. The aim of our study is to review the effectiveness of a physiotherapy triage clinic run by advanced practitioner physiotherapists (APP), who specialise in the review of upper limb referrals from primary care physicians.MethodsFor this study, a prospective, observational design was used. Patients were referred to the Department of Orthopaedic Surgery, Upper Limb Service at a national elective Orthopaedic Unit. The patients’ referrals were reviewed and allocated to a physiotherapy triage pathway if deemed routine, non-urgent cases. After assessment in the APP clinic, the physiotherapist made recommendations and highlighted patients who required review or case discussion with an orthopaedic surgeon. The discharge rate and outcome of patients referred on for further interventions or operative procedures was followed over a 3-year period. The outcomes for the patients were reviewed, including whether patients who met an orthopaedic surgeon went on to have surgical intervention.ResultsDuring the study, 646 patients were reviewed in an upper limb APP physiotherapy triage clinic. Of those reviewed, only 201 patients required review by an orthopaedic surgeon. Of those, 56 patients were scheduled for an operative procedure. Within the 3-year period, 50 patients of those scheduled underwent the procedure. The most commonly performed procedure being an arthroscopic subacromial decompression with or without acromioplasty or rotator cuff repair. A total of 145 patients referred by the physiotherapist had a shoulder injection including subacromial and glenohumeral intra-articular injection. The initial discharge rate was 68%.ConclusionsThere is a high initial discharge rate after initial assessment by APP triage clinics for upper limb musculoskeletal pathology. This is beneficial in alleviating waiting list pressures allowing only those patients in need of intervention to be placed on the ever expanding waiting lists to see orthopaedic surgeons. This study shows a high proportion of patients being offered surgical intervention after being referred by the APP. We conclude from this that the agreement between the physiotherapist’s initial diagnosis and that of the consultant surgeon being similar in identifying patients who would benefit from operative intervention.

A Multisite Injection Is More Effective Than a Single Glenohumeral Injection of Corticosteroid in the Treatment of Primary Frozen Shoulder: A Randomized Controlled Trial

To investigate the possible effects of multisite injection therapy around the shoulder and prospectively compare the pain relief, range of motion (ROM), and functional scores of randomly selected patients with primary frozen shoulder using the American Shoulder and Elbow Surgeons score and the University of California-Los Angeles score after the completion of a standard physiotherapy program. Seventy-six patients with primary frozen shoulder were randomly divided into 2 groups based on the treatment: multisite injection and single injection. In the multisite-injection group, the glenohumeral joint and posteroinferior capsule, subacromial space, posterosuperior capsule, biceps long head, and coracohumeral ligament were injected with a combination of 2 mL of triamcinolone acetonide (40 mg/mL), 4 mL of bupivacaine (0.5%), and 34 mL of saline solution. The glenohumeral joint in the single-injection group was injected with 1 mL of triamcinolone acetonide (40 mg/mL) and 2 mL of bupivacaine (0.5%). Patients in both groups underwent physical therapy using the same protocol. Patients were evaluated for pain (visual analog scale score), functional status, and active and passive joint ROM at 1, 3, and 6 months and 1 year after the injection. The follow-up rate was 82.6%, and significantly lower VAS scores were recorded in all periods in the multisite-injection group compared with the single-injection group (P= .01). In terms of active and passive ROM, the follow-up results were significantly better in the multisite-injection group (P < .05). Significantly higher functional scores were recorded in the multisite-injection group (P < .05). Both treatments were effective in patients with primary frozen shoulder. However, the multisite-injection technique provided better pain palliation, better ROM restoration, and better functional results than the single glenohumeral injection in patients with primary frozen shoulder who were treated with the same physiotherapy regimen. Level I, prognostic comparative study.

Effect of Arm Position on Visualization of Target Zone for Posterior Glenohumeral Joint Injection

Objectives: Glenohumeral injections can be performed using a variety of approaches. We hypothesize that the position of the ipsilateral arm affects the target zone for posterior approach of glenohumeral joints. Material and Methods: We performed ultrasound on three volunteers with arm with in neutral and varying degrees of flexion and extension. Results: We found that target zone is increased on flexion and decreased with arm in extension. Conclusion: Considering patient comfort, target zone, and operator ergonomics, we conclude that the posterior glenohumeral US-guided injections should be performed with patient lying on the contralateral side with the ipsilateral arm in neutral, and hand rested on the thigh (Birmingham Royal Orthopedic Hospital (BROH) position).

Efficacy of a single, image-guided corticosteroid injection for glenohumeral arthritis

Limited data are available on the efficacy of cortisone injections for glenohumeral osteoarthritis (GHOA). The amount and longevity of pain relief provided by a single cortisone injection are unclear. Additionally, it remains uncertain how the severity of radiographic GHOA and patient-reported function and pain levels impact the efficacy of an injection. Therefore, we sought to describe the relief provided by a single, image-guided glenohumeral injection in patients with GHOA. We hypothesized that patients with more severe radiographic GHOA and poorer baseline shoulder function would require earlier secondary intervention. Patients with symptomatic GHOA who elected to receive a corticosteroid injection for pain relief were prospectively enrolled. A phone interview was conducted to record the baseline Oxford Shoulder Score (OSS) and visual analog scale (VAS) scoreprior to the injection, as well as the OSS and VAS score at months 1, 2, 3, 4, 6, 9, and 12 after the injection. The endpoint of the study occurred when patients required a second injection, progressed to surgery, or reached month 12. Patients were grouped by their respective baseline OSS (mild vs. moderate or severe) and Samilson-Prieto radiographic classification (mild, moderate, or severe) for analysis. We analyzed 30 shoulders (29 patients). Of the patients, 52% were men. The average age was 66.1 years. No significant difference in overall survival (defined as no additional intervention) was seen between groups based on either the OSS or Samilson-Prieto grade. Additionally, the OSS and VAS scoreat each follow-up were compared with baseline values. For the entire cohort, a clinically significant difference was seen between baseline and months 1-4 for the OSS and between baseline and months 1-4, 6, 9, and 12 for the VAS score. This study aimed to determine the efficacy of corticosteroid injections for GHOA. There were no differences in the need for secondary interventionin this population based on the severity of either the OSS or the Samilson-Prieto radiographic classification. However, patients with more severe shoulder dysfunction based on the OSS did experience statistically significantly greater symptomatic relief than patients with milder dysfunction. Additionally, following a single injection, patients in this cohort experienced statistically and clinically relevant improvements in shoulder function and pain up to 4 months after injection.