Subacromial ultrasound guided or systemic steroid injection for rotator cuff disease: randomised double blind study. Ultrasound-guided shoulder injections in the treatment of subacromial bursitis. A randomized comparative study of short term response to blind injection versus sonographic-guided injection of local corticosteroids in patients with painful shoulder. Corticosteroid injections in adhesive capsulitis: investigation of their value and site. Ultrasound therapy of subacromial bursitis. A double blind trial.
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. To investigate the treatment effectiveness between ultrasound-guided and blind injection techniques in the treatment of subacromial bursitis.
                A total of 40 patients with sonographic confirmation of subacromial bursitis were recruited into this study. These patients were divided into blind and ultrasound-guided injection groups. The shoulder abduction range of motion was compared before injections and 1 wk after the completion of injections in both groups.
                The shoulder abduction range of motion before injection in the blind injection group was 71.03 +/- 12.38 degrees and improved to 100 +/- 18.18 degrees 1 wk after the injection treatments. However, the improvement did not reveal significant statistical differences (P > 0.05). The shoulder abduction range of motion before injection in the ultrasound-guided injection group was 69.05 +/- 14.72 degrees and improved to 139.29 +/- 20.14 degrees 1 wk after the injection treatments (P < 0.05).
                Ultrasound may be used as an adjuvant tool in guiding the needle accurately into the inflamed subacromial bursa. The ultrasound-guided injection technique can result in significant improvement in shoulder abduction range of motion as compared with the blind injection technique in treating patients with subacromial bursitis. 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. 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. 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.
Based upon moderate evidence from five trials, our review was unable to establish any advantage in terms of pain, function, shoulder range of motion or safety, of ultrasound-guided glucocorticoid injection for shoulder disorders over either landmark-guided or intramuscular injection. The lack of any added benefit of ultrasound guided subacromial bursal injection over glucocorticoid injection administered into the upper gluteal muscles of the buttock suggests that the benefits of glucocorticoid may arise through systemic rather than local effects. Therefore, although ultrasound guidance may improve the accuracy of injection to the putative site of pathology in the shoulder, it is not clear that this improves its efficacy to justify the significant added cost.