Subacromial Injection Research Articles

The comparative efficacy of kinesio taping and local injection therapy in patients with subacromial impingement syndrome

ObjectiveThe aim of this study was to compare the therapeutic effects of kinesio taping (KT) and local subacromial injection in patients with subacromial impingement, syndrome (SIS) with regard to pain, range of motion (ROM) and disability. MethodsSixty-one patients (48 females and 13 males; mean age: 43.04 ± 6.31, years) with SIS were enrolled into the study. The patients were randomized into two treatment groups receiving either a single corticosteroid and local anesthetic (LA) injection, or kinesio taping performed three times by intervals of 3 day. Visual analog scale (VAS) was used to assess pain intensity, range of motion (ROM) degrees of, shoulder were recorded and Shoulder Pain and Disability Index (SPADI) was, performed to evaluate functional disability, before treatment, at the first and fourth, weeks after therapies. A exercise program was prescribed for both groups including pendulum, active range of motion (ROM) and strengthening exercises. ResultsPain, functional outcome measures were determined to have improved significantly in both groups at the end of therapies at first and fourth weeks (p < 0.05), but these improvements were more significant in the injection group than in kinesio taping group (p < 0.05). The improvements in pain at rest, shoulder abduction degrees, and SPADI scores at first and fourth weeks were statistically higher in injection group than in kinesio taping group. ConclusionAlthough the improvement in pain intensity at rest, ROM and disability were better with local injection, KT may be an alternative noninvasive method to local subacromial injection for patients suffering from subacromial impingement syndrome. Level of EvidenceLevel I, Therapeutic study.

Corticosteroid injection for adhesive capsulitis in primary care: a systematic review of randomised clinical trials.

Adhesive capsulitis is a common cause of shoulder pain and limited movement. The objectives of this review were to assess the efficacy and safety of corticosteroid injections for adhesive capsulitis and to evaluate the optimum dose and anatomical site of injections. PubMed and CENTRAL databases were searched for randomised trials and a total of ten trials were included. Results revealed that corticosteroid injection is superior to placebo and physiotherapy in the short-term (up to 12 weeks). There was no difference in outcomes between corticosteroid injection and oral nonsteroidal anti-inflammatory drugs at 24 weeks. Dosages of intra-articular triamcinolone 20 mg and 40 mg showed identical outcomes, while subacromial and glenohumeral corticosteroid injections had similar efficacy. The use of corticosteroid injections is also generally safe, with infrequent and minor side effects. Physicians may consider corticosteroid injection to treat adhesive capsulitis, especially in the early stages when pain is the predominant presentation.

Extracorporeal shock wave therapy, ultrasound-guided percutaneous lavage, corticosteroid injection and combined treatment for the treatment of rotator cuff calcific tendinopathy: a network meta-analysis of RCTs.

Treatment of calcific tendinitis using extracorporeal shock wave therapy (ESWT), ultrasound-guided percutaneous lavage (UGPL or barbotage), subacromial corticosteroid injection (SAI) and combined treatment is still controversial. This systematic review and meta-regression aimed to compare clinical outcomes between treatments. Relevant RCTs were identified using PubMed and Scopus search engines to date of September 23, 2015. Seven of 920 studies identified were eligible. Compared to the other treatments, the results of this study indicate that ESWT significantly improved CMS and VAS when compared to placebo. Barbotage plus ESWT significantly improved CMS, VAS and decreased size of calcium deposit when compared to ESWT, while barbotage plus SAI significantly improved CMS and decreased size of calcium deposit when compared to SAI. There have no different adverse effects of all treatment groups. Multiple active treatment comparisons indicated that barbotage plus SAI significantly improved VAS and size of calcium deposit when compared to other groups, while barbotage plus SAI improved CMS when compared to other groups. But there was no significant difference. The network meta-analysis suggested that combined US-guided needling and subacromial corticosteroid injection significantly decreased shoulder pain VAS, improved CMS score and decreased the size of calcium deposits, while also lowering risks of adverse event when compared to barbotage plus ESWT, ESWT and subacromial corticosteroid injection; therefore, the evidence points to UGPL as being the treatment of choice for nonsurgical options of treatment in calcific tendinitis of the shoulder. Level of evidence I.

Subacromial injection of autologous platelet-rich plasma versus corticosteroid for the treatment of symptomatic partial rotator cuff tears.

Rotator cuff tears are one of the most common causes of chronic shoulder pain and disability. They significantly affect the quality of life. Reduced pain and improved function are the goals of conventional therapy, which includes relative rest, pain therapy, physical therapy, corticosteroid injections and surgical intervention. Tendons have a relative avascular nature; hence, their regenerative potential is limited. There is some clinical evidence that the application of autologous platelets may help to revascularize the area of injury in rotator cuff pathologies. This prospective randomized controlled study was done to evaluate the results of subacromial injection of platelet-rich plasma (PRP) versus corticosteroid injection therapy in 40 patients with symptomatic partial rotator cuff tears. All patients were assessed before injection, 6weeks, 3 and 6months after injection, using the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), the Constant-Murley Score (CMS), the Simple Shoulder Test (SST) and a Visual Analog Scale (VAS) for pain. An MRI was performed before and 6months after the injection for all the included patients and was graded on 0-5 scale. Both injection groups showed statistically significantly better clinical outcomes over time compared with those before injection. There was a statistically significant difference between RPP group and corticosteroid group 12weeks after injection, regarding VAS, ASES, CMS and SST in favor of the RPP group. MRI showed an overall slight nonsignificant improvement in grades of tendinopathy/tear in both groups, however, without statistically significant differences between the two groups. PRP injections showed earlier better results as compared to corticosteroid injections, although statistically significant better results after 6months could not be found. Therefore, subacromial RPP injection could be considered as a good alternative to corticosteroid injection, especially in patients with a contraindication to corticosteroid administration. II.

Normalization to Maximal Voluntary Contraction is Influenced by Subacromial Pain.

In this study, we aimed to determine if electromyography (EMG) normalization to maximal voluntary isometric contractions (MVIC) was influenced by subacromial pain in patients with subacromial impingement syndrome. Patients performed MVICs in unique testing positions for each shoulder muscle tested before and after subacromial injection of local anesthetic. In addition to collection of MVIC data, EMG data during an arm elevation task were recorded before and after injection. From a visual analog pain scale, patients had a 64% decrease in pain following the injection. Significant increases in MVICs were noted in 4 of the 7 shoulder muscles tested: anterior, middle and posterior deltoid, and lower trapezius. No significant differences were noticed for the upper trapezius, latissimus dorsi, or serratus anterior. MVIC condition (pre and post injection) had a significant influence on EMG normalization for the anterior deltoid and lower trapezius muscle. Results indicate that subacromial pain can influence shoulder muscle activity, especially for the deltoid muscles and lower trapezius. In addition, normalization to MVIC in the presence of pain can have unpredictable results. Caution should be taken when normalizing EMG data to MVIC in the presence of pain.

Lornoxicam injection is inferior to betamethasone in the treatment of subacromial impingement syndrome

Subacromial impingement syndrome (SIS) is one of the most frequent shoulder pathologies. Initial treatment is conservative. Subacromial injection of drugs achieves a high concentration at the pathologic site with less drug use and fewer systemic side effects. Glucocorticoids are most frequently injected. One concern with steroid use is the wide array of potential systemic and local complications. Nonsteroidal anti-inflammatory drugs (NSAIDs) are also peripherally acting and can be used locally. Although intraarticular (IA) use of NSAIDs is common in orthopedic practice, it is mostly restricted to the knee joint. Reports of local NSAID for joint pathologies are relatively rare. This study compared the efficacy of single-dose subacromial injections of betamethasone and lornoxicam for treatment of SIS. Subacromial injections of either 7.0mg betamethasone or 8mg lornoxicam were received by 70patients with mean age 53(46-68)years. Treatment outcome was assessed with Constant-Murley and UCLA questionnaires before injection and at 2‑, 4‑, and 6‑week follow-ups. The change in outcome scores compared to pretreatment was higher in the steroid group at all follow-ups (p<0.001). Patients in the steroid group showed asignificant improvement at all follow-ups compared to pretreatment (p<0.001) and previous follow-ups (p<0.05) at all times. Patients in the lornoxicam group showed asignificant functional improvement in week2 (p<0.001), which was not evident in the following weeks (p>0.05). Although functional recovery halted after week2, outcome scores remained significantly higher than the pretreatment values at all weeks (p<0.001). Although a single subacromial lornoxicam injection provides rapid functional recovery, which partially extends into the intermediate term, its results are inferior to betamethasone and it may be an alternative only in patients where corticosteroids are contraindicated.

Efficacy of a Subacromial Corticosteroid Injection for Persistent Pain After Arthroscopic Rotator Cuff Repair

Background: Corticosteroid injections have been widely used for reducing shoulder pain. However, catastrophic complications induced by corticosteroid such as infections and tendon degeneration have made surgeons hesitant to use a corticosteroid injection as a pain control modality, especially during the postoperative recovery phase. Purpose: To determine the effectiveness and safety of a subacromial corticosteroid injection for persistent pain control during the recovery period and to analyze the factors causing persistent pain after arthroscopic rotator cuff repair. Study Design: Cohort study; Level of evidence, 3. Methods: A total of 458 patients who underwent arthroscopic rotator cuff repair were included in this study. Patient-specific parameters, tear size and pattern, and pain intensity were reviewed. Seventy-two patients were administered a postoperative subacromial corticosteroid injection under ultrasound guidance. The corticosteroid injection was administered to patients who awakened overnight because of constant severe shoulder pain or whose pain was exacerbated at the time of rehabilitation exercises within 8 weeks after surgery. Pain intensity, patient satisfaction, and functional outcomes using the American Shoulder and Elbow Surgeons (ASES) and Constant scores were compared between the patients with and without a subacromial corticosteroid injection. The retear rate was evaluated with magnetic resonance imaging at 6 months postoperatively. Results: In patients with an injection, the mean (±SD) visual analog scale for pain (pVAS) score was 7.7 ± 1.2 at the time of the injection. This significantly decreased to 2.3 ± 1.4 at the end of the first month after the injection, demonstrating a 70.2% reduction in pain (P < .01). At 3 months after the injection, the mean pVAS score was 1.2 ± 1.8. Functional outcomes at final follow-up showed no significant differences between patients with and without an injection (ASES score: 90.1 ± 14.6 with injection, 91.9 ± 8.2 without injection [P = .91]; Constant score: 89.1 ± 12.9 with injection, 84.5 ± 13.0 without injection [P = .17]). Patients with an injection showed no significant increase in the retear rate (6.8% with injection, 18.4% without injection; P = .06). According to the tear pattern, L-shaped rotator cuff tears (41.8%) showed a higher occurrence of severe postoperative persistent pain. Preoperative shoulder stiffness was revealed as a predisposing factor for persistent pain (odds ratio, 0.2; P = .04). Conclusion: A subacromial corticosteroid injection can be considered as a useful and safe modality for the treatment of patients having severe persistent pain during the recovery phase after arthroscopic rotator cuff repair.

Agreement between a physiotherapist and orthopaedic surgeon regarding management of shoulder pain and prescription of subacromial corticosteroid injection

Agreement between a physiotherapist and orthopaedic surgeon regarding management of shoulder pain and prescription of subacromial corticosteroid injection

Functional Improvement after Sub-Acromial Corticosteroid Injection in Patient with Shoulder Impingement Syndrome

Background: Sub-acromial impingement syndrome (SAIS) is the most common disorder of shoulder. Conservative treatment is the first choice, often with corticosteroid injection or different physiotherapy interventions, or both. So we aimed to assess the mean reduction in shoulder pain and disability index (SPADI) score after administration of sub-acromial corticosteroid injections for management of SAIS.Objectives: To determine the mean reduction in SPADI score after administration of Sub-acromial corticosteroid injections for management of sub-acromial impingement syndrome.Material and Methods: The Quasi – experimental study was conducted in Department of Orthopedic Surgery, Mayo Hospital Lahore from November 2013 to august 2014. 150 cases were enrolled in this study. Then baseline SPADI score was noted. Patients were injected with sub-acromial injections of 40 mg triamcinolone acetonide mixed with 4.5 ml of 2% lignocaine under aseptic measures. All patients did exercises, consisting of pendulum and range of motion under care of physiotherapist. Each patient was followed-up in OPD for assessment of shoulder function according to SPADI score at 1, 3 and 6 weeks after administration of injection. The result was analyzed by using SPSS version 16.Results: The mean age of the patients was 44.58 ± 11.48 years. There were 46.67% males and 53.33% females in this study. The mean SPADI score of the patients at baseline was noted as 75.94 ± 7.73 which was reduced to 46.25 ± 5.62 after 6 weeks.Conclusion: Our study results concluded that Sub-acromial corticosteroid injection is effective in treatment of shoulder impingement syndrome.

Intra-articular injection, subacromial injection, and hydrodilatation for primary frozen shoulder: a randomized clinical trial

The aim of this prospective randomized study was to compare the efficacy of 3 injection methods, intra-articular injection, subacromial injection, and hydrodilatation (HD), in the treatment of primary frozen shoulder. Patients with primary frozen shoulder were randomized to undergo intra-articular injection (n = 29), subacromial injection (n = 29), or HD (n = 28). Evaluations using a visual analog scale for pain, Simple Shoulder Test, Constant score, and passive range of shoulder motion were completed before treatment and 1 month, 3 months, and 6 months after treatment. Among the 3 injection methods for primary frozen shoulder, HD resulted in a greater range of motion in forward flexion and external rotation, a lower visual analog scale score for pain after 1 month, and better outcomes for all functional scores after 1 month and 3 months of follow-up. However, there were no significant differences in any clinical outcomes among the 3 groups in the final follow-up at 6 months. Although HD yielded more rapid improvement, the 3 injection methods for primary frozen shoulder resulted in similar clinical improvement in the final follow-up at 6 months.

Effect of corticosteroid injections versus physiotherapy on pain, shoulder range of motion and shoulder function in patients with subacromial impingement syndrome: A systematic review and meta-analysis.

BackgroundSubacromial impingement syndrome (SIS) is one of the most common causes of shoulder pain. Limited research has been conducted into the efficacy of corticosteroid injections (CSIs) compared to physiotherapy in the management of SIS.ObjectiveTo critically appraise and establish the best available evidence for the effectiveness of CSI in comparison with physiotherapy for the management of pain, shoulder range of motion (ROM) and shoulder function in patients with SIS.MethodologySeven databases were searched from inception to February 2016, namely PubMed, Science Direct, EBSCO Host: SPORTDiscus, EBSCO Host: CINAHL, Cochrane, Scopus and PEDro. The main search terms were shoulder impingement syndrome and/or subacromial impingement syndrome, corticosteroid injections and/or steroid injections, physical therapy and/or physiotherapy. Only randomised controlled trials (RCTs) were considered for inclusion. The articles were appraised according to the PEDro scale. The Revman© Review Manager Software was used to combine the results of shoulder function and the data were illustrated in forest plots.ResultsThe PEDro scores of the three RCTs that qualified for this review ranged from 7 to 8/10. There is Level II evidence suggesting that besides a significant improvement in shoulder function in favour of CSI at 6–7 weeks follow-up (p < 0.0001), no evidence was found for the superiority of CSIs compared with physiotherapy for pain, ROM and shoulder function in the short- (1–3 months), mid- (6 months) and long term (12 months).ConclusionIn patients with SIS only a short term significant improvement in shoulder function was found in favour of CSIs.

Effects of lidocaine on torn rotator cuff tendons.

We determined lidocaine's action on torn rotator cuff tendons in vitro and in vivo. For in vitro experiments, cell proliferation and viability assays were performed using tenocytes derived from human torn rotator cuff tendons. For in vivo experiments, acute rotator cuff tears were made on the supraspinatus tendons in the rats' bilateral shoulders; before closure, lidocaine was injected into the shoulder and saline into the contralateral shoulder (control). After sacrifice, the specimens underwent biomechanical testing or histological analysis at 24 h and at 2, 4, and 8 weeks after surgery. The extent of collagen organization and apoptosis were semi-quantitatively evaluated using collagen picrosirius red staining. Apoptosis was examined using TUNEL staining and electron microscopy. Cell proliferation decreased dose-dependently. After exposure to 0.1% lidocaine for 24 h, cell viability decreased. Two and 4 weeks after surgery, the ultimate load to failure decreased more in the lidocaine group than in the control group, with significantly reduced stiffness in the lidocaine group 2 weeks after surgery. Collagen organization significantly decreased in the lidocaine group by 4 weeks after surgery but returned to baseline at 8 weeks. TUNEL staining detected numerous apoptotic tenocytes at the torn tendon edge exposed to lidocaine 24 h after surgery; electron microscopy confirmed the condensed cell nuclei. These changes were not observed in controls. Lidocaine caused cytotoxicity to tenocytes under both conditions, decreased biomechanical properties, and induced apoptosis and delay of collagen organization in this model. Subacromial lidocaine injections in patients with rotator cuff tears should be performed carefully. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:1620-1627, 2016.

Proper site of corticosteroid injection for the treatment of idiopathic frozen shoulder: Results from a randomized trial

ObjectiveThe objective is to determine whether corticosteroid injection into the subacromial space was not inferior to intra-articular injection in patients with idiopathic frozen shoulder (FS), and whether combined injections had an additive effect. MethodsPatients with idiopathic FS (n=126) were randomly assigned to receive ultrasound-guided intra-articular (IA group), subacromial (SA group), or combined IA and subacromial injections (IA+SA group). All groups received a total dose of 40mg triamcinolone acetonide. The outcome measures included the visual analog scale (VAS) for pain, American Shoulder and Elbow Surgeon (ASES) shoulder score, subjective shoulder value (SSV), and passive range of motion before and at 3, 6, and 12 weeks after treatment. ResultsThere was significant effect of time on all measurements such that all measures improved in all groups (P<0.001) during the 12 weeks after treatment. Group-by-time interactions were significant for ASES (P=0.006), VAS (P<0.001), SSV (P=0.03), and internal rotation (P=0.014). Between-group comparisons revealed a significant improvement in the IA (P<0.001) and IA+SA (P<0.001) groups as compared to the SA group. The IA+SA group demonstrated significant improvement in internal rotation as compared to the IA group (P=0.046). ConclusionThe efficacy of corticosteroid injection into the SA space in idiopathic FS was inferior to IA injection up to 12 weeks; however, combination injections had an additive effect on increasing the internal rotation angle. These results indicate that although the glenohumeral joint is a major site in the pathogenesis of idiopathic FS, the SA space may be a contributing site.

Ultrasound-Guided Versus Blind Subacromial Corticosteroid Injections for Subacromial Impingement Syndrome

Background: Subacromial corticosteroid injections are frequently performed for impingement syndrome of the shoulder. To improve the accuracy of injections, ultrasound can be used. Purpose: To assess the clinical outcome of ultrasound-guided subacromial injections compared with blind subacromial injections for subacromial impingement syndrome. Study Design: Randomized controlled clinical trial; Level of evidence, 1. Methods: A total of 56 shoulders with subacromial impingement syndrome were randomized into 2 groups: 28 shoulders received a subacromial corticosteroid injection with ultrasound guidance (ultrasound group), and 28 shoulders received a subacromial corticosteroid injection without ultrasound guidance (blind group). The visual analog scale (VAS) for pain with overhead activities and the American Shoulder and Elbow Surgeons (ASES) score were obtained before the injection and at 6 weeks after the injection. Results: The VAS score for pain with overhead activities decreased from 59 ± 5 mm (mean ± SEM) before the injection to 33 ± 6 mm at 6 weeks after the injection in the ultrasound group (P < .001) and from 63 ± 4 mm to 39 ± 6 mm, respectively, in the blind group (P < .001). The decrease in the VAS score was not significantly different between the groups (P > .999). The ASES score increased from 57 ± 2 before the injection to 68 ± 3 at 6 weeks after the injection in the ultrasound group (P < .01) and from 54 ± 3 before the injection to 65 ± 4 after the injection in the blind group (P < .01), with no significant difference between the groups (P = .7). Four shoulders (14%) in the ultrasound group and 6 shoulders (21%) in the blind group eventually needed surgery (P = .7). Conclusion: No significant differences were found in the clinical outcome when comparing ultrasound-guided subacromial injections to blind subacromial injections for subacromial impingement syndrome. Clinical Trial Registration: Australian New Zealand Clinical Trials Registry: ACTRN12615000562572

Efficacy of multimodal analgesia injection combined with corticosteroids after arthroscopic rotator cuff repair

IntroductionAlthough arthroscopic rotator cuff repair is minimally invasive, there is still considerable postoperative pain, especially during the first 48hours. The present study assessed the short-term efficacy and safety of multimodal analgesic (MMA) injection associated to corticosteroids in arthroscopic rotator cuff tear surgery. Material and methodA single-center prospective randomized study included 50 patients undergoing arthroscopic rotator cuff tear surgery. The study group received subacromial injection of a mixture of morphine, ropivacaine and methylprednisolone associated to intra-articular injection of morphine plus methylprednisolone; the control group received only isotonic saline. All patients had had 24hours self-administered morphine associated to standard analgesia. Postoperative data were recorded at 30minutes and 1, 2, 4, 6, 12, 18 and 24hours: pain intensity, morphine intake and side effects, and also time to first morphine bolus and additional analgesic intake. Constant, ASES and SST functional scores were recorded at 3 months. ResultsPostoperative pain was significantly less intense in the MMA group than in controls at 30min, H1, H4, H6, H12, H18 and H24 (P<0.05). A rebound at D10 occurred in both groups. During the first 24hours, MMA significantly reduced cumulative resort to morphine (P<0.05 at H1/2, P<0.001 at H1–24). Mean time to first bolus was significantly longer in the MMA group (71.6 vs. 33min; P<0.05). The rate of opioid-related side effects was similar between groups. At last follow-up, functional scores were similar between groups. There were no cases of infection or delayed skin healing. ConclusionMMA associated to corticosteroids after arthroscopic rotator cuff tear surgery provided immediate benefit in terms of analgesia and morphine sparing, without apparent risk of infection. The practice is presently little known in France and deserves longer-term assessment, especially as regards functional rehabilitation and tendon healing. Level of evidence2.

Detrimental Effect of Repeated and Single Subacromial Corticosteroid Injections on the Intact and Injured Rotator Cuff

Background: The effect of corticosteroids on tendons is poorly understood, and current data are insufficient and conflicting. Purpose: To evaluate the effects of corticosteroid injections on intact and injured rotator cuffs (RCs) through biomechanical and radiographic analyses in a rat model. Study Design: Controlled laboratory study. Methods: A total of 70 rats were assigned to 7 groups. Uninjured rats (no tear) received either a single saline injection, a single methylprednisolone acetate (MTA) injection, or triple MTA injections. Injured rats (unilateral supraspinatus injury) received either a single saline injection, triple saline injections, a single MTA injection, or triple MTA injections (injections were subacromial; repeat injections were administered weekly). Rats were sacrificed 1 week after final injection. Shoulders were harvested and grossly inspected, and the supraspinatus tendon was evaluated biomechanically. Bone density at the tendon insertion site on the greater tuberosity was assessed by micro–computed tomography. Results: Intact RCs exposed to triple MTA injections had significantly decreased maximal load and stiffness compared with the control group (14.43 vs 21.25 N and 8.21 vs 16.6 N/mm, respectively; P < .05). Injured RCs exposed to steroid treatment had significantly lower maximal load (single saline: 10.91 N, single steroid: 8.43 N [P < .05]; triple control: 15.77 N, triple steroid: 11.65 N [P < .05]) compared with the control at 3 weeks. Greater tuberosity volume density and connectivity density were significantly lower in undamaged rats after triple MTA injection (P < .05). Conclusion: The study results clearly showed that repeated doses of corticosteroids significantly weaken rat RC and negatively affect bone quality in addition to possibly causing deterioration of the osteotendinous junction. However, data retrieved from animals must be scrupulously analyzed before extrapolation to humans. As such, the potential benefits and harms of subacromial corticosteroid treatment must be considered before administration. Clinical Relevance: The potential benefit and detrimental effects of corticosteroid injection should be thoroughly considered before it is administered subacromially in patients with RC injuries.

Medium-term natural history of subacromial impingement syndrome

We evaluated the factors that affect the natural course of subacromial impingement syndrome in patients without rotator cuff tears. In total, 63 patients were included. During the first evaluation, we recorded each patient's age, gender, profession, body mass index (BMI), hand dominance, alcohol and tobacco consumption, comorbidities, causative event of pain, presence of a functional limitation, duration of symptoms, shoulder scores (American Shoulder and Elbow Surgeons [ASES], Constant-Murley, and visual analog scale), history of subacromial steroid injections, and magnetic resonance imaging (MRI) classification. A subacromial lidocaine injection test was performed to confirm the diagnosis, and patients were initially treated conservatively. Of the 63 patients, 7 underwent a subsequent surgical procedure. We recalled the patients and questioned them about recurrences. According to their answers, the patients were grouped as follows: group 1, no recurrence; group 2, relapsing course; and group 3, chronic course. We compared the groups regarding the factors proposed to affect the course of the disease. The mean follow-up time was 8.45±0.9years. There were no significant differences regarding gender, profession, hand dominance, alcohol consumption, smoking, comorbidities, causative event of pain, visual analog scale score, or history of subacromial steroid injections between groups. The patients in group 1 were significantly younger than those in group 2 (P=.038). The mean BMI value of the group 1 patients was significantly lower than that of the group 3 patients (P=.034). Patients with a functional limitation besides pain tended to have a relapsing course. The Constant-Murley and ASES scores were significantly higher for patients in group 1 than for patients in group 2 (P=.024 and P=.041, respectively). The duration of symptoms was significantly shorter (<3months) in group 1 (P=.001). Most of the patients in group 1 had reversible changes on MRI (P=.038). In our study, younger age, lower BMI, more functional capacity, a shorter symptomatic period, reversible changes on MRI, and higher Constant and ASES scores at the first evaluation were good prognostic factors.

Rotator cuff and subacromial pathology.

Both MRI and ultrasound (US) demonstrate equivalent accuracy in the evaluation of the rotator cuff. Both modalities have their advantages, disadvantages, and pitfalls. Radiography is an important complementary modality in that it can demonstrate occult sources of shoulder pain. MRI is recommended for the evaluation of shoulder pain in patients < 40 years of age because labral pathology is frequently identified. However, in patients > 40 years, US should be the first-line modality because the incidence of rotator cuff pathology increases with age. US is useful to guide procedures such as subacromial injection and calcific tendinosis lavage. Radiologists should be knowledgeable of both MRI and US of the shoulder to tailor these examinations to the specific needs of their patients.

DEVELOPMENT OF A JOINT INJECTION/ASPIRATION SIMULATION COURSE FOR SPECIALITY TRAINEES IN RHEUMATOLOGY

BackgroundThe JRCPTB* Training curriculum for Rheumatology mandates that trainees should be able to:1. Describe the surface anatomy of the musculoskeletal system2. Gain competences in joint and soft tissue injections.This is usually achieved in an informal basis. Simulation can provide a realistic learning opportunity to develop this skill. We designed and ran a simulation course to aid trainees in achieving these competencies.Methodology10 junior rheumatology trainees were invited to participate. The course started with a lecture which covered indications and contraindications to procedures including a summary of results from a regional survey of Rheumatology consultants and registrars on joint injection techniques. Faculty consisted of 4 Rheumatology Consultants and 3 Senior Registrars. At least one faculty member per station was present to provide instructions. Actors were used to demonstrate knee, shoulder and ankle/foot surface anatomy. Instructors demonstrated elbow, hand and wrist anatomy on themselves. Self-reported level of confidence using Likert score Pre and Post workshop questionnaires were used for evaluation.Results9/10 of the trainees felt that the session met their learning objectives. Confidence levels increased non-significantly in performing wrist, carpel tunnel, glenohumeral, subacromial and knee injection. Confidence levels increased significantly in performing ankle, acromoclavicular, elbow and epicondyle injections.ConclusionsIt is possible to successfully run a simulated joint injection course which can improve confidence levels in trainees.

One-year outcome of subacromial corticosteroid injection versus manual physical therapy for unilateral shoulder impingement syndrome: a pragmatic randomized clinical trial

Background: Corticosteroid injections (CSI) and physical therapy are often used to treat shoulder impingement syndrome, but their effectiveness has never been directly compared out to one year. Purpose:Theprimarypurposeof this studywas to directly compare the effectiveness of 2 common nonsurgical treatment approaches for shoulder impingement syndrome. The secondary purpose was to compare 1year healthcare utilization between the two groups. Methods: Patients referred to physical therapy received random assignment into 2 groups: 40mg triamcinalone acetonide subacromial CSI versus 6 sessions of manual physical therapy (MPT). Follow-up occurred at 1, 3, 6, and 12months. TheShoulder Pain andDisability Index (SPADI) served as the primary outcome. Secondary outcomes included the Global Rating of Change (GRC), the Numeric Pain Rating Scale (NPRS), and 1-year healthcare utilization based off electronic medical records review. Results:Over an 18-month period, 104 consecutive adults between 18 and 65 years of age with unilateral shoulder impingement were enrolled. Both groups demonstrated ∼50% improvement in SPADI at all 4 follow-ups maintained through 1 year, howevermean difference between groupswas not significant (1.5 [95% CI: 6.3, 9.4]). Both groups showed improvements in GRC and NPRS, but between group differences for the GRC (0 [95% CI: 2, +1]) and NPRS (0.4 [95% CI: 0.5, 1.2]) were not significant. During the 1-year followup, patients receiving CSI hadmore SIS-related visits to their primary care provider (60% vs. 37%), required additional steroid injections (38% vs. 20%), and 19% needed physical therapy (compared to 9% in the MPT group). Conclusion(s): Patients randomized to the MPT group experienced similar outcomes in terms of function, pain and patient perceived improvement as patients receiving CSI. However they utilized significantly less additional healthcare resources than the CSI patients for the following year after initial treatment. Implications: CSI and MPT are two common conservative treatment options offered to patients with shoulder impingement. Understanding their long-term impact and the comparative effectiveness of each can help guide best evidence care decisions. Disclaimer:The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Departments of the Army or Defense.