Corticosteroid injections in adhesive capsulitis: investigation of their value and site. Subacromial ultrasound guided or systemic steroid injection for rotator cuff disease: randomised double blind study. A randomized comparative study of short term response to blind injection versus sonographic-guided injection of local corticosteroids in patients with painful shoulder. Comparison of injection techniques for shoulder pain: results of a double blind, randomised study. Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis. [Adhesive capsulitis of the shoulder: a comparative study of arthrography with intra-articular corticotherapy and with or without capsular distension]. Manipulation under anesthesia for frozen shoulder with and without steroid injection. Efficacy of injections of corticosteroids for subacromial impingement syndrome. Rotator cuff tendinitis: comparison of subacromial injection of a long acting corticosteroid versus oral indomethacin therapy. Randomized controlled trial for efficacy of intra-articular injection for adhesive capsulitis: ultrasonography-guided versus blind technique. Effectiveness of corticosteroid injections versus physiotherapy for treatment of painful stiff shoulder in primary care: randomised trial. [Transdermal nitroglycerin versus corticosteroid infiltration for rotator cuff tendinitis]. Intra-articular corticosteroids are effective in osteoarthritis but there are no clinical predictors of response. Intra-articular triamcinolone acetonide injection in patients with capsulitis of the shoulder: a comparative study of two dose regimens. Treatment of "frozen shoulder" with distension and glucorticoid compared with glucorticoid alone. A randomised controlled trial. Intramuscular botulinum toxin-A reduces hemiplegic shoulder pain: a randomized, double-blind, comparative study versus intraarticular triamcinolone acetonide. Intra-articular botulinum toxin A for refractory shoulder pain: a randomized, double-blinded, placebo-controlled trial. Osteoarthritis of the temporomandibular joint: an evaluation of the effects and complications of corticosteroid injection compared with injection with sodium hyaluronate. Ultrasound therapy of subacromial bursitis. A double blind trial.
Forty-eight patients with frozen shoulder for less than six months were assigned at random to receive three shoulder injections into the subacromial bursa or glenohumeral joint at weekly intervals. The treatment groups were (1) intra-articular methylprednisolone and lidocaine, (2) intrabursal methylprednisolone and lidocaine, (3) intra-articular lidocaine, (4) intrabursal lidocaine. The same physical therapy program was carried out for all patients. Assessments of pain and range of motion were performed by a physical therapist who was uninformed about the nature of the injection therapy. There was no significant difference in outcome between intrabursal injection and intra-articular injection. Injection of steroid with lidocaine had no advantage over lidocaine alone in restoring shoulder motion, but partial, transient pain relief occurred in two thirds of the steroid-treated patients. To compare the effectiveness of ultrasound guided corticosteroid injection in the subacromial bursa with systemic corticosteroid injection in patients with rotator cuff disease.
                Double blind randomised clinical trial.
                Outpatient clinic of a physical medicine and rehabilitation department in Oslo, Norway. Patients 106 patients with rotator cuff disease lasting at least three months.
                Ultrasound guided corticosteroid and lidocaine injection in the subacromial bursa and lidocaine injection in the gluteal region (local group); corticosteroid and lidocaine injection in the gluteal region and ultrasound guided lidocaine injection in the subacromial bursa (systemic group).
                Difference in improvement in the overall shoulder pain and disability index score after six weeks.
                Six weeks after the intervention, the mean difference in improvement in overall shoulder pain and disability index score between the local group and the systemic group was -5.2 (95% confidence interval -13.9 to 3.5); it was -4.1 (-12.3 to 4.1, P=0.32) after adjustment for baseline score. A small but statistically significant difference in improvement between groups occurred in favour of the local group for two secondary outcome measures: the Western Ontario rotator cuff index (8.1, 0.7 to 15.6) and change in main complaint (2.0, 0 to 4).
                No important differences in short term outcomes were found between local ultrasound guided corticosteroid injection and systemic corticosteroid injection in rotator cuff disease.
                Clinical trials NCT00640575. Local corticosteroid injections, commonly accepted by rheumatologists to be effective treating painful shoulder, have shown controversial results. High frequency ultrasonography is an accurate and safe imaging modality for guiding musculoskeletal injections. We prospectively compared the short term response to randomized blind injection versus sonographic-guided injection of local corticosteroid in patients with painful shoulder.
                We studied 41 consecutive patients with painful shoulder. Patients with previous trauma or chronic inflammatory arthritis were excluded. No patient had received previous physiotherapy or local steroid injection in the shoulder. Patients were randomized to receive either a blind subacromial injection of 20 mg triamcinolone (Group 1, n = 20) or a sonographic guided injection of 20 mg triamcinolone (Group 2, n = 21) by the same rheumatologist blinded to the clinical evaluation. In both groups we recorded shoulder abnormalities and the location of the steroid postinjection by ultrasound. Each patient was clinically assessed within 5 days before injection and 6 weeks after injection by another rheumatologist without knowledge of the injection technique performed. Clinical assessment included demographic and clinical data, a visual analog scale (VAS) for pain (0-100), the Shoulder Function Assessment (SFA) scale (0-70), and postinjection adverse effects. No patient received physical therapy during the followup period. Initially, demographic, clinical, and ultrasonographic findings in both groups showed no significant differences.
                Six weeks after injection, the VAS and the SFA score showed a significantly greater improvement in Group 2 compared with Group 1 (mean VAS score change 34.9 for Group 2 vs 7.1 for Group 1, p < 0.001; and mean SFA score change 15 for Group 2 vs 5.6 for Group 1, p = 0.012). One patient in Group 1 reported mild postinjection adverse effects.
                We suggest that sonographic-guided corticosteroid injections should be indicated, at least, in patients with poor response to previous blind injection to ensure accurate medication placement in order to improve therapeutic effectiveness. Seventy seven patients with soft tissue shoulder lesions including adhesive capsulitis and disorders of the rotator cuff and acromioclavicular joint were admitted to a trial comparing two different methods of corticosteroid injection with local anaesthetic in a randomly allocated double blind study. The method of anatomical injection after diagnosis by the technique of selective tissue tension gave 60% success compared with the method using tender or trigger point localisation, giving 20% success (p less than 0.001). Adhesive capsulitis is a common musculoskeletal disorder mainly affecting middle aged adults. It is associated with generalized pain and tenderness in the shoulder joint with severe loss of active and passive ranges of motion in all planes. The aim of this study was to compare the efficacy of local steroid injection and physical therapy measures for treating this disorder. Ten male and 10 female patients were enrolled in the study. The patients were divided randomly into two groups and treated with either 40 mg methylprednisolone acetate injection with local anesthetic (group A) or physical therapy measures plus nonsteroidal anti-inflammatory drugs (group B). The mean ages of the patients were 55.6+/-12.2 years in group A and 56.4+/-7.1 years in group B. Clinical assessment was performed on initial visit and at the 2nd and 12th weeks. Active and passive range of motion was recorded and the visual analogue scale was used to evaluate pain intensity. At initial visit, these data in both groups of patients were not statistically different. Although both treatment regimens resulted in significant improvement in range of motion, the differences between mean external rotation at the 2nd and 12th weeks were not statistically significant in either group. The improvement in range of motion at the end of the study was similar in both groups (P>0.05). All patients reported improvement during the study. The differences between mean VAS scores at the 2nd and 12th weeks were statistically significant in both groups. In conclusion, local steroid injection therapy was found to be as effective as physical therapy for the treatment of adhesive capsulitis. A double-blind, prospective study of 45 patients with adhesive capsulitis of the shoulder compared the therapeutic efficacy of distensive and nondistensive arthrography in combination with the intra-articular injection of corticosteroids. After 1 and 3 months there was no significant difference between the two treatments in the degree of pain or of limitation of movement experienced by the patients. More than 80% of the patients who experienced pain at rest and nocturnal pain improved under both treatment regimens. Scapulohumeral mobility increased significantly but only partially within the first month of treatment. Articular capacity and the duration of symptoms before treatment were of no prognostic value. To study the effect of manipulating a shoulder with adhesive capsulitis (frozen shoulder) under anesthesia with and without corticosteroid injection.
                Randomized trial.
                Hospital.
                Twenty-four patients referred for manipulation of a frozen shoulder.
                The patients were randomized into 2 groups. One group received an injection of corticosteroid and manipulation; the other was only administered manipulation during anesthesia.
                The degree of shoulder mobility and pain before and after the manipulation.
                Manipulation under anesthesia increased the mobility of the affected shoulder. Injection with lidocaine and betamethason did not enhance the effect of the manipulation.
                Manipulation under anesthesia without intraarticular corticosteroids is recommended as the therapy for frozen shoulder. A prospective, randomized, controlled, double-blind clinical study was performed to determine the short-term efficacy of subacromial injection of corticosteroids for the treatment of subacromial impingement syndrome. Forty patients were randomized to receive either six milliliters of 1 per cent lidocaine without epinephrine (the control group) or two milliliters containing forty milligrams of triamcinolone acetonide per milliliter with four milliliters of 1 per cent lidocaine without epinephrine (the corticosteroid group). The patients were re-examined serially until completion of the study. Nineteen patients, whose mean age was fifty-six years (range, thirty-two to eighty years), were randomized to the corticosteroid group, and twenty-one patients, whose mean age was fifty-seven years (range, thirty-two to eighty-one years), were randomized to the control group. The mean duration of symptoms before the injection was eight months for both groups. Eighteen patients in the corticosteroid group and nineteen patients in the control group had moderate or severe pain before the injection. At the most recent follow-up evaluation, at a mean of thirty-three weeks for the corticosteroid group and twenty-eight weeks for the control group, three patients in the corticosteroid group had moderate or severe pain, compared with fifteen patients in the control group. The mean active range of forward elevation and external rotation improved by 24 and 11 degrees, respectively, for the corticosteroid group and by 10 and 5 degrees, respectively, for the control group. We concluded that subacromial injection of corticosteroids is an effective short-term therapy for the treatment of symptomatic subacromial impingement syndrome. The use of such injections can substantially decrease pain and increase the range of motion of the shoulder. Using a prospective, double blind, double dummy protocol, we compared the efficacy of subacromial injection of 40 mg of triamcinalone acetonide versus oral indomethacin, 100 mg/day, in 40 patients with acute rotator cuff tendinitis. Repeat injection and refill of medication was given after 3 weeks, if necessary. At 6 weeks, there was no significant difference between the 2 groups with respect to the percentage of patients who improved (60 vs 66%) or the magnitude of the change of pain and motion variables. This study suggests that there is essentially no difference in the short term efficacy of oral nonsteroidal therapy compared to local corticosteroid injection(s) in the treatment of rotator cuff tendinitis. Lee H-J, Lim K-B, Kim D-Y, Lee K-T. Randomized controlled trial for efficacy of intra-articular injection for adhesive capsulitis: ultrasonography-guided versus blind technique.
                To evaluate the clinical effect of ultrasonography (US)-guided intra-articular injections compared with a blind (unguided) technique for the treatment of adhesive capsulitis.
                Randomized controlled trial.
                Outpatient rehabilitation clinic.
                Patients (N=43) diagnosed as having adhesive capsulitis after clinical examinations and radiologic and ultrasonographic study.
                Under either US-guided or a blind technique, patients received a 20-mg intra-articular injection of triamcinolone mixed with 1.5mL 2% lidocaine and 4mL normal saline in the first week followed by 5 weekly injections of sodium hyaluronate.
                A visual analog scale for pain intensity, range of motion (ROM) of the shoulder (flexion, abduction, external rotation, and internal rotation), and general shoulder function during daily activities at preinjection as a baseline and then every week after injection for 6 weeks for each patient.
                Twenty patients out of 22 in the blind injection group and 20 out of 21 in the US-guided group finished the entire 6-week study period. The improvement in pain intensity, ROM, and shoulder function score was significantly greater in the US-guided injection group than in the blind injection group by the second week postinjection (P<.05). However, there were no further significant differences in the improvement between the 2 groups beyond the third week.
                US-guided intra-articular injections may offer advantages over a blind technique for the treatment of adhesive capsulitis and may deliver clinical benefits during the first few weeks of treatment. This finding suggests that the improved targeting to the intra-articular space by using US can result in better treatment of adhesive capsulitis. To compare the effectiveness of corticosteroid injections with physiotherapy for the treatment of painful stiff shoulder.
                Randomised trial.
                40 general practices.
                109 patients consulting general practitioners for shoulder pain were enrolled in the trial.
                Patients were randomly allocated to 6 weeks of treatment either with corticosteroid injections (53) or physiotherapy (56).
                Outcome assessments were carried out 3, 7, 13, 26, and 52 weeks after randomisation; some of the assessments were done by an observer blind to treatment allocation. Primary outcome measures were the success of treatment as measured by scores on scales measuring improvement in the main complaint and pain, and improvement in scores on a scale measuring shoulder disability.
                At 7 weeks 40 (77%) out of 52 patients treated with injections were considered to be treatment successes compared with 26 (46%) out of 56 treated with physiotherapy (difference between groups 31%, 95% confidence interval 14% to 48%). The difference in improvement favoured those treated with corticosteroids in nearly all outcome measures; these differences were statistically significant. At 26 and 52 weeks differences between the groups were comparatively small. Adverse reactions were generally mild. However, among women receiving treatment with corticosteroids adverse reactions were more troublesome: facial flushing was reported by 9 women and irregular menstrual bleeding by 6, 2 of whom were postmenopausal.
                The beneficial effects of corticosteroid injections administered by general practitioners for treatment of painful stiff shoulder are superior to those of physiotherapy. The differences between the intervention groups were mainly the result of the comparatively faster relief of symptoms that occurred in patients treated with injections. Adverse reactions were generally mild but doctors should be aware of the potential side effects of injections of triamcinolone, particularly in women. To compare transdermal nitroglycerin (NTG) and corticosteroid infiltration in patients with rotator cuff tendinitis (RCT).
                Experimental, randomized controlled study.
                Semirural basic health area in the Garraf region of Barcelona province, Spain, with a population of public health service users of 12000.
                Patients diagnosed as having RCT of less than 6 weeks' evolution who had not responded to treatment with oral nonsteroid antiinflammatory drugs. The patients were distributed randomly into two groups: a) group A, local infiltration via a posterior approach with a depot corticosteroid and local anesthesia, and b) group B, treated for 3 days with a 5-mg NTC patch.
                Age, sex, pain (measured with an analog visual scale) and adverse events. In patients who showed a partial response, treatment was repeated up to 3 times at 15-day intervals. Pain was tested after 7-10 days of treatment. Complete improvement was considered a reduction in pain of more than 5 points on the analog visual scale; partial improvement was considered a reduction of 3-5 points, and treatment failure was recorded when there was no improvement in pain or when there was a decrease of less than 3 points.
                A total of 48 patients were included; 33 (69%) were women and 15 (31%) were men. Mean age was 61 years. In group A, complete improvement was seen in 19 patients and partial improvement in 3; treatment failed in 2 patients. In group B complete improvement was seen in 5 patients, partial improvement in 5, and failure of treatment in 14. The difference between groups was statistically significant. Adverse events were mild pain at the injection site in 4 patients from group A, and headache in 15 patients from group B, 8 of whom abandoned treatment for this reason.
                Treatment with NTG is not a clear alternative to infiltration of corticosteroids in patients with RCT, because of its lack of effectiveness and because of the greater number of patients who had adverse events that lead them to abandon treatment. To show whether intra-articular steroid injections are effective in osteoarthritis; to determine factors that predict response; and to determine whether injection has a beneficial effect on muscle strength.
                Double blind, placebo controlled, crossover study in 59 patients with symptomatic osteoarthritis of the knee. Outcome measure-Primary outcome measure: change in visual analogue score for pain at three weeks. Predictors of response analysed using logistic regression with a 15% decrease in pain score at three weeks defining response.
                Intra-articular methyl prednisolone acetate produced a significant reduction in visual analogue pain score at three weeks compared to both baseline (median change -2.0 mm, interquartile range -16.25 to 4.0) and placebo (median 0.0 mm, interquartile range -9.0 to 6.25). No clinical predictors of response could be identified. Muscle strength was not significantly improved in the short term by intra-articular injection.
                Intra-articular corticosteroids are effective for short term relief of pain in osteoarthritis but predicting responders is not possible. There may be a place for their more widespread use. Although corticosteroid injections have been reported to be effective in capsulitis of the shoulder, the optimal dose has not been established. The purpose of this study was to compare relief of symptoms following a lower dose with that following a higher dose of triamcinolone acetonide given intra-articularly.
                Thirty-two patients were given low dose suspension; 25 patients were given high dose suspension.
                Randomized, double-blind clinical trial. Each patient was given a course of three injections. Pain, sleep disturbance, functional impairment and passive range of motion (ROM) were assessed at intake and at one, three and six weeks after the initial injection. Data were analysed by independent sample t-tests and nonparametric Mann-Whitney U-tests.
                The group which received the 40 mg dose showed significantly greater improvement than the group receiving the 10 mg dose.
                The study shows that in the treatment of frozen shoulder greater symptom relief is obtained with a dose of 40 mg triamcinolone acetonide intra-articularly than with a dose of 10 mg. The effect on pain and sleep disturbance was more marked than on ROM. Intra-articular injections with triamcinolone acetonide appear to be an effective method to obtain symptom relief for patients with painful capsulitis of the shoulder. This study is a comparison of treatments of idiopathic "Frozen Shoulder" (adhesive capsulitis), distension combined with steroid is compared with steroid alone. Evaluation was based on pain scales, analgesic usage, and range of motion outcome scales. Out of one-hundred twenty patients (age, mean 51, range 21-70) that were referred under the diagnosis FS, twenty-six fulfilled the criteria for inclusion in the study, but four patients did not want to participate in the trial, giving a total of 22 patients (age, mean 53, range 40-65) in the study. Patients were randomised by the envelope method. Two patients dropped-out, one in each treatment group thus leaving the study with 20 patients for the final statistical analysis. Eight were treated with steroid alone and 12 with distension combined with steroid. Patients received one treatment per week for a six weeks period with a follow-up at 12 weeks. They were evaluated by pain VAS on function and at rest within the study period, the different ranges of motion (ROM) were measured at inclusion time and subsequent afterwards at 3, 6, and 12 weeks. The VAS outcomes showed no difference between the treatments (VAS-function p=0,1; VAS-rest p=0.1), while in the distension group ROM showed significant improvement in all directions except extension (external p=0.0007, flexion p=0.03, extension p=0,01). The analgesic usage was significantly lower in the group treated with distension at the end of the study (p=0.008). A blinded clinical assessment of ROM also showed significant improvement (p=0.002). It is concluded that distension with steroid can seem to help in management of "Frozen Shoulder". Other studies seems to support the conclusion. Shoulder pain is frequent after stroke and interferes with the rehabilitative process and outcome. However, treatments used for hemiplegic shoulder pain are limited and largely ineffective. This prospective, randomized, double-blind controlled study was conducted to compare the efficacies of botulinum toxin type A (BoNT-A) and triamcinolone acetonide (TA) on hemiplegic shoulder pain and their effects on arm function in patients with stroke.
                Twenty-nine hemiplegic stroke patients with shoulder pain (duration <or=24 months, pain on numeric rating scale >or=6/10) were randomized into 2 groups. One group received intramuscular injections of BoNT-A (BOTOX 100 U total) during one session to the infraspinatus, pectoralis and subscapularis muscles in conjunction with an intraarticular injection of normal saline to painful shoulder joint, whereas the other group received an intraarticular injection of TA (40 mg) and an intramuscular injection of normal saline to the same muscles. Outcome measures were pain (measured using a numeric rating scale), physician's global rating scale, shoulder range of motion (ROM) in 4 directions, arm function measured using Fugl-Meyer score, and spasticity measured using the modified Ashworth scale. Measurements were made at baseline and 2, 6, and 12 weeks after injection.
                At 12 weeks after treatment mean decrease in pain was 4.2 in the BoNT-A-treated group versus 2.5 in the TA-treated group (P=0.051), and improvements in overall ROM were 82.9 degrees versus 51.8 degrees in these groups (P=0.059), showing a strong trend toward there being less pain and better ROM among those treated with BoNT-A than with TA. However, no significant differences were observed between the 2 groups in terms of improvement in physician global rating, Fugl-Meyer score or modified Ashworth scales. No adverse effect was observed in either group.
                Results from this study suggest that injection of BoNT-A into selected muscles of the shoulder girdle might provide more pain relief and ROM improvement than intraarticular steroid in patients with hemiplegic shoulder pain. A larger clinical trial needs to be undertaken to confirm the benefits of this approach. We compared the short-term efficacy and safety of intra-articular (IA) botulinum toxin A (BoNT/A) to IA-placebo in patients with chronic, refractory shoulder joint pain. Forty-three shoulder joints in patients with moderate-to-severe shoulder arthritis pain were randomized to receive (1) 100 units IA-BoNT/A + lidocaine or (2) IA-saline + lidocaine. The following outcomes were compared using analysis of covariance: (1) primary: change in pain severity on a visual analog scale at 1 month (VAS, 0 cm to 10 cm); (2) secondary: Shoulder Pain and Disability Index (SPADI) disability subscale, quality of life on short-form (SF)-36 subscales, percent of patients who achieved at least a 30% decrease or a 2-point reduction in VAS pain (clinically meaningful pain relief), and safety. Both BoNT/A (n = 21) and placebo (n = 22) groups were comparable at baseline. At 1 month post-injection, the VAS pain reduction was significantly more in the BoNT/A group versus the placebo group (-2.4 vs -0.8; P-value = 0.014). When comparing BoNT/A with the placebo group at 1 month, it was observed that 5 SF-36 subscale scores improved significantly (P </= 0.035), and the SPADI disability improved more with a trend toward significance (51.5 +/- 4.4 vs 64.9 +/- 3.9; P = 0.083). In addition, clinically meaningful pain relief occurred in 61% versus 36% patients (P = 0.22). The total number of adverse events was similar, which included 50 events in the BoNT/A group versus 46 events in the placebo group. A single injection of BoNT/A produced statistically significant and clinically meaningful pain relief and improvement in quality of life in patients with chronic refractory moderate/severe shoulder arthritis pain at 1 month. These data provide evidence to support the efficacy of this novel neurotoxin therapy that needs to be confirmed in a multicenter, randomized trial. The purpose of this study was to compare the efficacy and the complications of intra-articular temporomandibular joint (TMJ) injections in 40 patients with osteoarthritis of the TMJ. The subjects were randomly divided into two groups, and the patients received either two intra-articular injections with sodium hyaluronate or two intra-articular injections with corticosteroids, 14 days apart. The effect of the treatment was evaluated 14 days, 1 and 6 months after the initial injection and was based on the following measurements: pain intensity, pain localization, joint sounds, mandibular function and complications. Both groups of patients had less pain intensity at the 6-month follow-up, and there was significantly less pain intensity in the group of patients receiving sodium hyaluronate compared with corticosteroids (P = 0.001). A decrease in crepitation was seen in both groups. In the 20 subjects receiving sodium hyaluronate both the mandibular vertical opening and protrusion increased significantly (P < 0.000). Lateral movement from the affected side increased both in subjects injected with sodium hyaluronate (P = 0.024), and those injected with corticosteroids (P = 0.042). In conclusion, this study confirms that injections in the TMJ with sodium hyaluronate or corticosteroids may reduce pain and improve function in patients with osteoarthritis. The injections were more effective in patients with only TMJ pain compared with patients suffering from both TMJ and myofascial pain. Injection with sodium hyaluronate was significantly more effective in decreasing pain intensity than corticosteroids. Temporary pain after injections may be observed. Ultrasound (US) is used widely to treat patients with supraspinatus tendinitis, subacromial bursitis, or adhesive capsulitis (SSA). No double blind studies of US in the treatment of SSA, however, have been conducted. This study was designed to determine whether the addition of US can further decrease pain and increase range of motion in those receiving the usual courses of ROM exercises and nonsteroidal anti-inflammatory drugs (NSAIDs) or ROM exercises in patients with SSA. Twenty patients with SSA were randomized to receive true or sham US three times a week for four weeks. All other aspects of treatment remained constant (ROM exercises and NSAIDs or ROM exercises). The physician, the physical therapist, and the patients were blinded throughout the study regarding the delivery of the true or sham US. Of the multiple variables analyzed (pain, ROM, and function), no significant difference was found between the sham or true US groups. Although the study group was small, the results suggest that US is of little or no benefit when combined with ROM exercises and NSAIDs or ROM exercises in the treatment of SSA.
Despite many RCTs of corticosteroid injections for shoulder pain, their small sample sizes, variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment. Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained. 
There is a need for further trials investigating the efficacy of corticosteroid injections for shoulder pain. Other important issues that remain to be clarified include whether the accuracy of needle placement, anatomical site, frequency, dose and type of corticosteroid influences efficacy.