Corticosteroid injections for shoulder pain (Review)

Buchbinder R, Green S, Youd JM

This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library
2003, Issue 1
http://www.thecochranelibrary.com

Corticosteroid injections for shoulder pain (Review)

Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
AUTHORS CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
WHATS NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Corticosteroid injections for shoulder pain (Review) i

Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
[Intervention Review]

Corticosteroid injections for shoulder pain

Rachelle Buchbinder1 , Sally Green2 , Joanne M Youd3

1 Monash Department of Clinical Epidemiology at Cabrini Hospital, Department of Epidemiology and Preventive Medicine, Monash
University, Malvern, Australia. 2 Monash Institute of Health Services Research, Monash University, Clayton, Australia. 3 c/- Ivy Suite
Bendat Family Comprehensive Cancer Centre, St John of God Hospital Subiaco, Subiaco, Australia

Contact address: Rachelle Buchbinder, Monash Department of Clinical Epidemiology at Cabrini Hospital, Department of Epidemiology
and Preventive Medicine, Monash University, Suite 41, Cabrini Medical Centre, 183 Wattletree Road, Malvern, Victoria, 3144,
Australia. [email protected].

Editorial group: Cochrane Musculoskeletal Group.

Publication status and date: Edited (no change to conclusions), published in Issue 1, 2009.
Review content assessed as up-to-date: 18 November 2002.

Citation: Buchbinder R, Green S, Youd JM. Corticosteroid injections for shoulder pain. Cochrane Database of Systematic Reviews 2003,
Issue 1. Art. No.: CD004016. DOI: 10.1002/14651858.CD004016.

Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

ABSTRACT
Background
While many treatments, including corticosteroid injections in and around the shoulder, are advocated to be of benefit for shoulder pain,
few are of proven efficacy. This review of corticosteroid injections for shoulder pain is one in a series of reviews of varying interventions
for shoulder disorders.
Objectives
To determine the efficacy and safety of corticosteroid injections in the treatment of adults with shoulder pain.
Search methods
MEDLINE, EMBASE, CINAHL, Central and Science Citation Index were searched up to and including June 2002.
Selection criteria
Randomised and pseudo-randomised trials in all languages of corticosteroid injections compared to placebo or another intervention,
or of varying types and dosages of steroid injection in adults with shoulder pain. Specific exclusions were duration of shoulder pain less
than three weeks, rheumatoid arthritis, polymyalgia rheumatica and fracture.
Data collection and analysis
Trial inclusion and methodological quality was assessed by two independent reviewers according to predetermined criteria. Results
are presented separately for rotator cuff disease, adhesive capsulitis, full thickness rotator cuff tear and mixed diagnoses, and, where
possible, combined in meta-analysis.
Main results
Twenty-six trials met inclusion criteria. The number, site and dosage of injections varied widely between studies. The number of
participants per trial ranged from 20 to 114 (median 52 participants). Methodological quality was variable.
For rotator cuff disease, subacromial steroid injection was demonstrated to have a small benefit over placebo in some trials however no
benefit of subacromial steroid injection over NSAID was demonstrated based upon the pooled results of three trials.
Corticosteroid injections for shoulder pain (Review) 1
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
For adhesive capsulitis, two trials suggested a possible early benefit of intra-articular steroid injection over placebo but there was
insufficient data for pooling of any of the trials. One trial suggested short-term benefit of intra-articular corticosteroid injection over
physiotherapy in the short-term (success at seven weeks RR=1.66 (1.21, 2.28).

Authors conclusions

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.

PLAIN LANGUAGE SUMMARY

Corticosteroid injections for shoulder pain

Corticosteroid injections may be of limited short-term benefit for shoulder pain

The available evidence from randomized controlled trials supports the use of subacromial corticosteroid injection for rotator cuff
disease, although its effect may be small and short-lived, and it may be no better than non-steroidal anti-inflammatory drugs. Similarly,
intra-articular steroid injection may be of limited, short-term benefit for adhesive capsulitis. Further trials investigating the efficacy of
corticosteroid injections for shoulder pain are needed. Important issues that need clarification include whether the accuracy of needle
placement, anatomical site, frequency, dose and type of corticosteroid influences efficacy.

BACKGROUND been performed is often hampered by the fact that these disorders
are labelled and defined in diverse and often conflicting ways. In
This review is one in a series of reviews aiming to determine the
our previous review we also undertook a methodological review
evidence for efficacy of common interventions for shoulder pain.
of the selection criteria used in these studies and concluded that
This series of reviews form the update of an earlier Cochrane
more research is needed to establish a uniform method of defining
Review of all interventions for shoulder disorders (Green 1998a,
shoulder disorders.
Green 1998b).
Since our previous review many new clinical trials, studying a di-
Shoulder pain is common with a reported prevalence of 6.9 to 34%
verse range of interventions, have been performed. In order to up-
in the general population and 21% in those over 70 years of age
date our review we have therefore subdivided it into a series of re-
(Chard 1991). Shoulder disorders account for 1.2% of all general
views investigating the evidence for efficacy of single interventions.
practice encounters, being third only to back and neck complaints
We have also broadened our review to include all randomised or
as musculoskeletal reasons for primary care consultation (Rekola
pseudo-randomised clinical trials regardless of whether outcome
1993). They are also a cause of significant morbidity (Chard 1991,
assessment was blinded.
Croft 1996). Although there are many accepted standard forms
of conservative therapy for shoulder disorders, evidence of their This review examines the evidence for efficacy and safety of corti-
efficacy is not well established. Our previous systematic review of costeroid injections for the treatment of adults with shoulder pain.
randomized controlled trials investigating these treatments con- Corticosteroid injections are a commonly used modality to treat
cluded that there was very little evidence to either support or re- shoulder pain irrespective of underlying aetiology. Corticosteroid
fute the efficacy of interventions commonly used to treat shoulder may be injected into the glenohumeral joint via an anterior or
pain. Furthermore, the interpretation of results of studies that have posterior approach, into the subacromial space, tendon sheaths of
Corticosteroid injections for shoulder pain (Review) 2
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
specific tendons, or locally into trigger or tender points. These are shoulder pain. Specific exclusions were duration of shoulder pain
usually performed by the clinician who uses anatomical landmarks less than three weeks, rheumatoid arthritis, polymyalgia rheumat-
to guide blinded placement of the needle. Apart from placement ica and fracture.
of the injection into various anatomical sites, other variations in In our previous review, we performed a methodological review of
the use of steroid injections include single or multiple injections the selection criteria used in the included studies (Green 1998b).
over time; injection of different sites at one time; use of different Study populations were broadly able to be categorised as either ad-
corticosteroid preparations, different volumes and types of local hesive capsulitis (which included frozen shoulder and periarthritis)
anesthetic; and different total volumes of injection. This review or rotator cuff disease (which included supraspinatus tendonitis,
aims to review the evidence of efficacy and safety of steroid injec- infraspinatus tendonitis, rotator cuff tendonitis, rotator cuff le-
tions in the treatment of shoulder pain taking into account these sion, bursitis or subscapularis tendonitis) based upon the diagnos-
issues. tic labels and/or definitions of these labels when described. Some
trials did not specify a diagnosis and some trials gave no selection
criteria or study population definition (Green 1998b). For this
OBJECTIVES review we were broadly able to categorise the participants as adhe-
sive capsulitis (including frozen shoulder and periarthritis), rotator
To determine the efficacy and safety of corticosteroid injections in cuff disease, full thickness rotator cuff tear and mixed diagnoses
the treatment of patients with shoulder pain. (more than one diagnostic label or definition of study population
not clearly specified).

METHODS
Types of interventions
All randomised controlled comparisons of corticosteroid injec-
Criteria for considering studies for this review tions versus placebo, or another modality, or of varying types and
dosages of steroid injection were included, and comparisons es-
tablished according to intervention. Studies that included steroid
injection in more than one arm were not included unless they
Types of studies
provided information about the benefit of steroid injection. For
This review was conducted following a peer reviewed a priori pro- example trials that compared steroid injection plus another inter-
tocol. vention to steroid injection alone do not provide any information
a) Randomised or pseudo-randomised controlled trials. Studies about the benefit of steroid injection eg. Thomas et al compared
where participants were not randomised into intervention groups steroid injection and manipulation under anaesthesia to steroid
were excluded from the review. injection alone (Thomas 1980). This has been included in the
surgery review.
b) Trials in which allocation to treatment or control group was not
concealed from the outcome assessor were not excluded. A sen-
sitivity analysis including and excluding these trials was planned, Types of outcome measures
because foreknowledge of treatment allocation may lead to biased No studies were excluded on the basis of outcome measure used.
assessment of outcome. Reported outcomes included pain (at night, at rest, and on move-
c) Studies in all languages were translated into English and con- ment), range of motion (active and/or passive: flexion, abduction,
sidered for inclusion in the review. A sensitivity analysis including external rotation, internal rotation and hand behind back), func-
and excluding foreign language trials was planned to test the effect tion, strength, and return to work or school.
of inclusion of these trials.

Types of participants Search methods for identification of studies

Inclusion in this review was restricted to trials with participants We searched MEDLINE, EMBASE, CINAHL (includes all ma-
meeting the following criteria: jor physiotherapy and occupational therapy journals from U.S.A.,
All studies which primarily concerned pain arising from the shoul- Canada, England, Australia and New Zealand), and Science Ci-
der in adult populations (greater than 18 years of age) were in- tation Index (SCISEARCH) up to and including June 2002 .
cluded irrespective of diagnostic label. For studies that included The Cochrane Musculoskeletal Review Groups optimally sen-
various regional painful disorders such as shoulder and elbow pain, sitive search strategy (see below) was used to identify all possi-
we included their data if the results for shoulder pain were pre- ble randomised controlled trials. Keywords gained from previous
sented separately or if 90% or more of the study participants had reviews and all relevant articles were searched as text terms and

Corticosteroid injections for shoulder pain (Review) 3

Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
any additional keyword identified from subsequent articles was Validity of included trials was assessed by comment on whether
searched again. As this review is one of a series concerning differ- they met key criteria (appropriate randomisation, allocation con-
ent interventions for shoulder pain, various interventions were in- cealment, blinding, number lost to follow up and intention to
cluded in the search strategy and all searches combined as a single treat analysis). These criteria were selected on the basis of being
endeavour. important for potentially biasing the overall outcome of trials. The
1 Shoulder Pain/ (376) only scoring was given for allocation concealment, ranked as:
2 Shoulder Impingement Syndrome/ (351) A: adequate
3 Rotator Cuff/ (931) B: unclear
4 exp Bursitis/ (419) C: inadequate
5 ((shoulder$ or rotator cuff ) adj5 (bursitis or frozen or impinge$ D: not used
or Whether or not trials were appropriately randomised (as described
tendinitis or tendonitis or pain$)).mp. (1911) in the Cochrane Handbook, Clarke 2000), included blinded par-
6 rotator cuff.mp. (1253) ticipants, care providers and outcome assessor, had complete fol-
7 adhesive capsulitis.mp. (69) low up and used an intention to treat analysis was recorded on
8 or/1-7 (3122) a pre-piloted data extraction sheet and later transposed into the
9 exp INJECTIONS/ (39394) Characteristics of Included Studies table. Validity of trials was
10 ((steroid$ or corticosteroid$ or sub-acromial or subacromial) assessed in this way as opposed to using a numerical or summary
adj5 scale due to concerns regarding the validity of such scales and
inject$).mp. (1121) lack of information about whether all the criteria included in such
11 or/9-10 (39957) scales impact on the overall outcome of the trial (Juni 1999).
12 Clinical trial.pt. (137491) DATA EXTRACTION AND ANALYSIS
13 random$.mp. (133940) In order to assess efficacy, raw data for outcomes of interest (means
14 ((single or double) adj (blind$ or mask$)).mp. (23539) and standard deviations for continuous outcomes and number of
15 placebo$.mp. (30562) events for binary outcomes) were extracted where available from
16 or/12-15 (224241) the published reports. All standard errors of the mean were con-
17 8 and 11 and 16 (60) verted to standard deviation, and, when necessary, standard devi-
18 from 17 keep 1-60 (60) ation was imputed from the range by division by four. Wherever
Further electronic searches for key authors identified were made, reported data was converted or imputed, this was recorded in the
and a record of these searches kept. Print outs of all search strategies notes section of the included studies table. For trials where the
were compiled and stored for future reproduction and review if required data was not reported or able to be calculated, further
required. details were requested from first authors. If no further details were
In addition, the Cochrane Controlled Trials Register (CCTR) Is- provided, the trial was included in the review and fully described,
sue 2, 2002 was searched. but not included in the meta-analysis (i.e. no pooling of study
data). An entry to that effect was made in the notes section of the
included studies table.
Data collection and analysis When trial results were not normally distributed and so reported as
median and range, the trial was not included in the meta-analysis
Following identification of potential trials for inclusion by the pre-
but results presented in Additional Tables.
viously outlined search strategy, the methods sections of all iden-
Meta-analysis was facilitated by RevMan 4.1. The following
tified trials were reviewed independently according to predeter-
choices of statistic and 95% confidence intervals were presented
mined criteria (see selection criteria), by two of three investiga-
for all outcomes.
tors (RB, SG, JY). All articles were coded and details of source,
intervention, population and funding recorded. The investigator
CONTINUOUS OUTCOMES:
compiling the references (RB) decided on potentially relevant tri-
Weighted mean difference using a fixed effects model was selected
als (based on the article being a randomised controlled trial of a
when outcomes were measured on standard scales. When out-
steroid injection for the treatment of shoulder pain), excluding
comes were reported on non standard scales, using differing units
those where it was clear the intervention and population did not
and methods of assessment (for example disability scales), a stan-
meet the inclusion criteria. There were no disagreements with re-
dardised mean difference was selected. Possible clinical reasons for
spect to inclusion of trials into the review.
heterogeneity were explored, and in the presence of significant
Trials meeting inclusion criteria were collated, and the methods
heterogeneity, trial results were not combined.
and results sections were re-assessed by the same two of three
DICHOTOMOUS OUTCOMES:
reviewers (RB, SG, JY) for assessment of validity.
Relative risk using a fixed effects model was selected for interpreta-
ASSESSMENT OF VALIDITY

Corticosteroid injections for shoulder pain (Review) 4

Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
tion of dichotomous outcome measures in this review as this is the review (Green 1998a, Green 1998b) and similar issues are appli-
most appropriate statistic for the interpretation when the event is cable to the current review.
common (Deeks 1998). Reasons for heterogeneity were evaluated DESCRIPTION OF INTERVENTIONS ACCORDING TO
and in the event of significant heterogeneity trial results were not STUDY POPULATION
pooled. 1. ADHESIVE CAPSULITIS
SENSITIVITY ANALYSIS For adhesive capsulitis, intra-articular steroid injection was com-
Three sensitivity analyses were planned. pared to placebo in one trial (Rizk 1991); no treatment in one
1. Trials in which the outcome assessor was not blinded were to trial (Lee 1973); physiotherapy in one trial (van der Windt 1998);
be excluded to assess the possible effect of detection bias. physiotherapy and non-steroidal anti-inflammatory drug in one
2. Trials published in languages other than English were to be trial (Arslan 2001); capsular distension in two trials (Gam 1998,
excluded to assess the possible effect of publication bias. Jacobs 1991); ice in one trial (Bulgen 1984); infra-red irradiation
3. Trials for which the method of randomisation was unclear were in one trial (Lee 1973); and stellate ganglion block in one trial
to be excluded to assess their effect upon the conclusion of the (Williams 1975). One trial compared a combination of both intra-
review. articular and subacromial steroid injection to no treatment and
to physiotherapy (Bulgen 1984); one trial compared high versus
low dose intra-articular steroid injection (de Jong 1998); and the
anterior and posterior intra-articular approach was compared in
RESULTS one trial (White 1996). Intra-articular steroid injection was com-
pared to subacromial and intrabursal injections in one trial (Rizk
1991), and bicipital injection in one trial (Lee 1973). One trial
Description of studies compared steroid injected anteriorly around the shoulder joint to
physiotherapy (Dacre 1989) (this was included within the intra-
See: Characteristics of included studies; Characteristics of excluded
articular steroid versus physiotherapy comparisons). There were
studies.
three trials that studied intra-articular steroid injection combined
Forty potential trials were identified and 26 met the inclusion
with another intervention (with physiotherapy versus physiother-
criteria. Reasons for study exclusion were lack of randomization
apy alone (Dacre 1989); with capsular distension versus capsular
(n=7), heterogeneous study population or included rheumatoid
distension alone (Jacobs 1991); with manipulation under anaes-
arthritis (n=3), did not provide any information about the value
thesia versus manipulation under anaesthesia alone (Kivimcki
of steroid injection per se (n=3), or no outcome data reported (n=
2001). One trial also compared steroid injected into the synovial
1). The 13 excluded trials and details of why they failed to meet
sheath surrounding the bicipital tendon with no treatment (Lee
the inclusion criteria for this review are outlined in the Table of
1973).
Characteristics of Excluded Studies.
2. ROTATOR CUFF DISEASE
Details of the 26 included trials are given in the Table of Char-
For rotator cuff disease, there were seven trials that compared sub-
acteristics of included Studies. Twenty-five of the 26 included tri-
acromial steroid injection to placebo (Adebajo 1990, Blair 1996,
als were published in English, and one was published in German
Kirkley 1999, Petri 1987, Plafki 2000, Strobel 1996, Vecchio
(Strobel 1996). The number of participants per trial ranged from
1993) and one trial that compared supraspinatus tendon injec-
20 to 114 (median 52 participants) and one trial did not specify
tion to placebo (Withrington 1985). There were three trials that
number of participants (Williams 1975).
compared subacromial steroid injection to non-steroidal anti-in-
STUDY POPULATION
flammatory medication (Adebajo 1990, Petri 1987, White 1986)
Based upon review of the diagnostic labels and/or definitions of
and one trial that compared combination subacromial steroid in-
the study populations, the included trials could be broadly cate-
jection and anti-inflammatory medication to non-steroidal anti-
gorised as studying adhesive capsulitis (including periarthritis and
inflammatory medication alone (Petri 1987). One trial com-
frozen shoulder) (12 trials) (Arslan 2001, Bulgen 1984, Dacre
pared crystalline versus lipoid subacromial steroid injection (Plafki
1989, de Jong 1998, Gam 1998, Jacobs 1991, Kivimcki 2001,
2000). One 5-arm trial compared intra-articular steroid injection
Lee 1973, Rizk 1991, van der Windt 1998, White 1996, Williams
to placebo, physiotherapy and acupuncture and also compared
1975); rotator cuff tendonitis (including impingement, subacro-
intra-articular steroid injection and non-steroidal anti-inflamma-
mial bursitis, partial rotator cuff tears)(10 trials) (Adebajo 1990,
tory medication to placebo (Berry 1980).
Berry 1980, Blair 1996, Kirkley 1999, Petri 1987, Plafki 2000,
3. FULL THICKNESS ROTATOR CUFF TEARS
Strobel 1996, Vecchio 1993, White 1986, Withrington 1985);
For full thickness rotator cuff tears, there was one trial that com-
full thickness rotator cuff tear (1 trial) (Shibata 2001); or a com-
pared intra-articular steroid injections to intra-articular injections
bination of diagnoses (3 trials) (Hollingworth 1983, Richardson
of hyaluronate (Shibata 2001).
1975, Winters 1997). The lack of uniformity in the way shoulder
4. MIXED POPULATION OF SHOULDER PAIN
disorders are labelled and defined was highlighted in our previous

Corticosteroid injections for shoulder pain (Review) 5

Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
For the mixed population of patients, one trial compared tender the approach was not described in four trials (Hollingworth
or trigger point injections to anatomical steroid injections (site 1983, Kivimcki 2001, Shibata 2001, Williams 1975). Injections
determined by clinical features) (Hollingworth 1983); one trial were placed into the subacromial space (or bursa) in 11 trials
compared a combination of both intra-articular and subdeltoid (Adebajo 1990, Blair 1996, Hollingworth 1983, Kirkley 1999,
bursal injections to placebo (Richardson 1975); and one trial com- Petri 1987, Plafki 2000, Richardson 1975, Rizk 1991, Vecchio
pared intra-articular injections to manipulation or physiotherapy 1993, White 1986, Winters 1997). Other sites included ante-
(Winters 1997). riorly around the shoulder joint (Dacre 1989); acromioclavicu-
STEROID PREPARATION, FREQUENCY OF INJECTION lar joint (Hollingworth 1983, Winters 1997); supraspinatus ten-
AND VOLUMES don (Hollingworth 1983, Withrington 1985); infraspinatus and
There was a wide variation in the corticosteroid preparation used, subscapularis tendons (Hollingworth 1983) and bicipital tendon
the dosage, number of injections given and their timing. Twelve sheath (Lee 1973).
trials (46.2%) used triamcinolone: a single 80 mg triamcinolone Most studies (22/26, 84.6%) did not confirm the accurate place-
hexacetomide injection (one trial: Adebajo 1990); a single 40 mg ment of the injection. Two studies used ultrasound to confirm
triamcinolone acetonide injection (three trials: Blair 1996, Petri needle placement (intra-articular Gam 1998; sub-acromial Plafki
1987, White 1986); a single 20 mg triamcinolone hexacetomide 2000). Richardson performed an arthrogram following steroid in-
injection (two trials Dacre 1989, Strobel 1996); a single 10mg tri- jection and reported that the injection was intra-articular only
amcinolone acetonide injection (one trial Plafki 2000); up to six inconstantly when intra-articular injection was performed using
injections (at weekly intervals) of 20 mg triamcinolone hexaceto- the posterior approach, but readily obtained when subacromial
mide (one trial Gam 1998); three injections (at six week intervals) injection was performed (Richardson 1975). White et al mixed
of 40mg triamcinolone acetonide (one trial Jacobs 1991); three urograffin with the corticosteroid preparation and took post-in-
injections (at a one week then two week interval) of either 10 mg jection plain films. They reported that 10/20 (50%) intra-articu-
or 40mg triamcinolone actonide (one trial de Jong 1998); no more lar injections using the posterior approach were correctly placed,
than three injections over six weeks of 40mg triamcinolone ace- compared to 19/20 (95%) using the anterior approach (White
tonide (one trial van der Windt 1998); and one to nine injections 1996).
(one to three initially then one to three one week later, then one to OUTCOME ASSESSMENT
three, two weeks later) of 40mg triamcinolone (one trial Winters Our previous review highlighted the wide variation in assessment
1997). Seven trials (26.9%) used methylprednisolone: a single of outcome in clinical trials investigating the efficacy of interven-
40mg injection of methylprednisolone acetate (four trials Arslan tions for painful shoulder (Green 1998a, Green 1998b) and simi-
2001; Berry 1980; Hollingworth 1983, Vecchio 1993); a single 80 lar issues are applicable to the current review. Of the 26 included
mg methylprednisolone injection (one trial Withrington 1985); trials, 23 trials (88.5%) included some measure of pain and 23
three injections (at weekly intervals) of 20mg methylprednisolone trials (88.5%) reported at least one measure of shoulder range of
(one trial Bulgen 1984); and three injections (at weekly intervals) movement. The method of assessment of shoulder range of move-
of 40 mg methylprednisolone (one trial Rizk 1991). Three trials ment, including description of the instrument used, and how end
(11.5%) used hydrocortisone: a single injection of 25mg hydro- of range was defined was recorded for only a minority of studies.
cortisone acetate (two trials Lee 1973; White 1996); and three Function was assessed in nine studies (34.6%) measured by simple
injections (at weekly intervals) of 50mg hydrocortisone (one trial four or six-point scales in three trials (Adebajo 1990, de Jong 1998,
Williams 1975). Two trials used dexamethasone (7.7%): a single Petri 1987); work status in one trial (Strobel 1996) and incorpo-
injection of 2.5 mg dexamethasone (Plafki 2000) (note: Plafki et al rated within an overall score in two trials (Patte score Plafki 2000;
compared triamcinolone to dexamethasone), and up to five injec- UCLA score Shibata 2001). Two trials used a previously validated
tions (at weekly intervals) of 2mg dexamethasone (Shibata 2001). shoulder disability index (Shoulder Disability Questionnaire (van
Two trials (7.7%) used a single injection of 6mg betamethasone der Windt 1998); Disabilities of the Arm, Shoulder and Hand
(Kirkley 1999, Kivimcki 2001); one trial used two injections (a (DASH Kirkley 1999) while one trial developed their own shoul-
fortnight apart) of 50 mg prednisolone acetate (Richardson 1975). der disability index based upon ability to perform five activities of
The total volume injected varied between two and 25 mls and the daily living (Blair 1996). The clinimetric properties of this instru-
use of local anaesthetic also varied widely. ment were not reported. The final assessment for efficacy ranged
ANATOMICAL SITE OF INJECTION from four weeks to one year (median 12 weeks).
Injections were placed into the glenohumeral joint via a poste-
rior approach in eight trials (Arslan 2001, de Jong 1998, Gam
1998, Jacobs 1991, Richardson 1975, van der Windt 1998,
White 1996, Winters 1997); an anterior approach in five tri- Risk of bias in included studies
als (Berry 1980, Bulgen 1984, Lee 1973, Rizk 1991, White
The included studies were of varying methodological quality. A
1996); a superior approach in one trial (Strobel 1996); and
description of the methodological quality of each of the included

Corticosteroid injections for shoulder pain (Review) 6

Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
trials is displayed under the Methods heading of the Table of Char- INTRA-ARTICULAR STEROID INJECTION VERSUS
acteristics of included studies. PLACEBO FOR ROTATOR CUFF DISEASE
Only four trials were considered to have adequate allocation con- One trial that compared a single intra-articular steroid injection
cealment (Adebajo 1990, de Jong 1998, Petri 1987, van der Windt (of 40mg methylprednisolone) to placebo for rotator cuff disease
1998). Allocation concealment was inadequate in two trials, un- provided sufficient data for meta-analysis (Berry 1980). No benefit
clear in 17 trials and not used in three trials. of steroid injection over placebo was demonstrated at four weeks
Outcome assessment was blinded in 19 trials (73.1%) (Adebajo with respect to pain, range of abduction or success of therapy
1990, Berry 1980, Blair 1996, Bulgen 1984, Dacre 1989, de (Berry 1980). Participants in this trial were only blinded to some
Jong 1998, Gam 1998, Hollingworth 1983, Jacobs 1991, Kirkley interventions. There were no other trials comparing intra-articular
1999, Petri 1987, Plafki 2000, Richardson 1975, Rizk 1991, steroid injection to placebo for rotator cuff disease.
van der Windt 1998, Vecchio 1993, White 1986, Winters 1997, INTRA-ARTICULAR STEROID INJECTION
Withrington 1985), unclear in four trials (15.4%) (Arslan 2001, VERSUS PLACEBO OR NO TREATMENT FOR ADHESIVE
Kivimcki 2001, Shibata 2001, Strobel 1996), and not blinded in CAPSULITIS
three trials (11.5%) (Lee 1973, White 1996, Williams 1975). Neither of the two trials that compared intra-articular steroid in-
Participants were blinded in 13 trials (50%) (Adebajo 1990, Blair jection to either placebo (Rizk 1991) or no treatment (Lee 1973)
1996, de Jong 1998, Gam 1998, Hollingworth 1983, Kirkley in adhesive capsulitis provided sufficient data for meta-analysis.
1999, Petri 1987, Plafki 2000, Richardson 1975, Rizk 1991, The outcome of these trials varied, with Rizk et al reporting no
Vecchio 1993, White 1986, Withrington 1985); not blinded in differences between intra-articular steroid injection and placebo
eight trials (30.8%) (Arslan 2001, Bulgen 1984, Dacre 1989, Lee with respect to pain and range of movement up to six months
1973, van der Windt 1998, White 1996, Williams 1975, Winters (double-blind, intention to treat analysis) (Rizk 1991); and Lee et
1997); unclear in four trials (15.4%) (Jacobs 1991, Kivimcki al reporting significant benefit of injection over analgesia alone up
2001, Shibata 2001, Strobel 1996); and partially blinded in one to six weeks (unblinded, results only displayed graphically) (Lee
trial (3.9%) (Berry 1980). 1973). Lee et al also reported significant benefit of bicipital tendon
Five trials did not specify whether there was any loss to follow- sheath injection over analgesia alone.
up (Blair 1996, Bulgen 1984, Kirkley 1999, Lee 1973, Williams INTRA-ARTICULAR AND SUB-ACROMIAL STEROID IN-
1975). Loss to follow up was greater than 20% in at least one JECTION VERSUS NO TREATMENT FOR ADHESIVE
treatment group in four trials that reported loss to follow up ( CAPSULITIS
Kivimcki 2001, Strobel 1996, White 1986, Winters 1997). One trial that compared a combination of intra-articular and sub-
Twelve trials (46.2%) performed an intention to treat analyses acromial steroid injection to no treatment for adhesive capsulitis
(Adebajo 1990, Arslan 2001, Berry 1980, Hollingworth 1983, did not provide sufficient data for meta-analysis (Bulgen 1984). It
Jacobs 1991, Petri 1987, Plafki 2000, Rizk 1991, van der Windt reported little difference with respect to long-term outcome but
1998, White 1986, Winters 1997, Withrington 1985); seven some early benefit of injection with respect to pain and range of
(26.9%) reported a completers analyses only (Dacre 1989, Gam movement (only outcome assessment blinded, statistical analysis
1998, Kivimcki 2001, Richardson 1975, Shibata 2001, Strobel unclear).
1996, Vecchio 1993) the appropriateness of the analysis was un- SUB-ACROMIAL STEROID INJECTION VERSUS
clear in five trials (26.9%) (Blair 1996, Bulgen 1984, de Jong 1998, PLACEBO FOR ROTATOR CUFF DISEASE
Kirkley 1999, Williams 1975); data was only presented graphi- The results of two trials involving a total of 45 participants that
cally in one (3.9%) (Lee 1973); and no analysis was reported in compared subacromial steroid injection to placebo in rotator cuff
one trial (3.9%) (White 1996). disease could be pooled (Adebajo 1990, Petri 1987) (comparison
Only 12 trials (46.2%) presented sufficient data to be included in 2). There was a small benefit of subacromial steroid injection over
meta-analysis. placebo at four weeks with respect to pain (SMD 0.83, 95% CI
0.39, 1.26), function (SMD 0.63 ((95% CI 0.20, 1.06) and range
of active abduction (SMD 0.82, 95% CI 0.39, 1.25) (Adebajo
1990, Petri 1987). Both of these trials were double-blind (partici-
Effects of interventions pants and outcome assessment), no loss to follow-up was reported
and an intention to treat analysis was performed.
The results of the 12 trials with sufficient data to be included in
It was not possible to combine the results of the other five trials
the meta-analyses are displayed in the Table of Comparisons and
that compared subacromial steroid injection to placebo for rotator
Data and are described below.
cuff disease. Two of these trials reported some benefit of injection
A summary of the results of the included trials with insufficient
over placebo (Blair 1996, Plafki 2000). Blair et al however found
data to be included in meta-analyses are displayed in the Table of
no difference with respect to performance of activities of daily
Characteristics of included studies and are also described below
living (double-blind but analysis and loss to follow up unclear)
where applicable.

Corticosteroid injections for shoulder pain (Review) 7

Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
(Blair 1996). Plafki at al reported benefit after six months of steroid Only one of the three trials comparing intra-articular steroid injec-
injection in 19 of 40 participants in one of the two groups that tion to physiotherapy contained sufficient data for meta-analysis
received steroid injection, although another eight participants in (56 participants) (van der Windt 1998). At seven weeks, treatment
the steroid groups required surgery (double blind, study stopped success favoured steroid injection (RR=1.66, 95% CI 1.21, 2.28).
after first 10 participants in placebo group failed to improve and At three and seven weeks, all outcomes measured favoured steroid
aggravation of symptoms in four participants) (Plafki 2000). Two injection (including improvement in severity of main complaint,
double-blind trials reported no differences between the treatment pain during the day, pain at night, pain as rated by an observer,
groups (Kirkley 1999, Vecchio 1993), although one has only been functional disability and abduction). By 13 weeks, benefit favour-
reported in abstract thus far (Kirkley 1999). One trial favoured the ing steroid injection remained statistically significant only for im-
placebo group with respect to improvement in pain at three and 12 provement in severity of main complaint. No difference in out-
months although more participants in the steroid injection group come was demonstrated for any of the measured outcomes at 26
resumed work at 12 months (Strobel 1996). However the blinding weeks and a small benefit favouring steroid injection was found
of this study was unclear, the analysis included completers only for improvement in severity of main complaint at 52 weeks. No
and there was a large loss to follow up in both groups (30 and 15% statistically significant differences were found with respect to fre-
in the injection and placebo groups respectively) (Strobel 1996). quency of adverse effects in the two treatment groups apart from
ANATOMICAL STEROID INJECTION (SITE DETER- facial flushing which was more common in the steroid injection
MINED BY CLINICAL FEATURES) VERSUS TRIGGER OR group (RR=9.0, 95% CI 1.18, 68.74). While participants in this
TENDER POINT INJECTION FOR GENERAL SHOUL- were unblinded, the study population included 109 participants,
DER PAIN AND SUBGROUP EXCLUDING ADHESIVE there was a low withdrawal rate (3.6% and 7.5% from the physio-
CAPSULITIS therapy and steroid injection groups respectively) and an intention
One trial demonstrated that anatomical steroid injection was su- to treat analysis was performed.
perior to trigger or tender point injection with respect to success It was not possible to combine the results of the other two trials
rate after one week for 43 participants with general shoulder pain that compared intra-articular steroid injection to physiotherapy
(RR = 2.96, 95% CI 1.62, 5.42), as well as in a subgroup of 33 par- for adhesive capsulitis. Bulgen compared a combination of both
ticipants excluding adhesive capsulitis (RR = 2.55, 95% CI 1.45, intra-articular and subacromial steroid injection to physiotherapy
4.47) (Hollingworth 1983). This trial was double-blind, there was and reported little difference between groups with respect to long-
no reported loss to follow-up and an intention to treat analysis term outcome but some early benefit of the combined injections
was performed. with respect to pain and range of movement (only outcome assess-
HIGHER DOSE VERSUS LOWER DOSE INTRA-ARTICU- ment blinded, statistical analysis unclear) (Bulgen 1984). Dacre et
LAR STEROID INJECTION FOR ADHESIVE CAPSULITIS al, which compared steroid injection placed anteriorly around the
One trial compared two doses of intra-articular steroid injection shoulder joint to physiotherapy reported no significant differences
in adhesive capsulitis. While a trend favouring higher dose intra- between groups at 6 weeks and 6 months (only outcome assess-
articular steroid injection was found with respect to improvement ment blinded, four patients of unspecified group lost to follow-up
in pain at six weeks (WMD=-18.10, 95% CI -37.11, 0.91), no and a completers analysis only) (Dacre 1989).
differences were found between the higher and lower dose steroid INTRA-ARTICULAR STEROID INJECTION VER-
injection with respect to improvement in sleep disturbance, func- SUS PHYSIOTHERAPY AND NON-STEROIDAL ANTI-IN-
tional impairment or improvement in external rotation (57 par- FLAMMATORY MEDICATION (NSAID) FOR ADHESIVE
ticipants) (de Jong 1998). No statistically significant differences CAPSULITIS
were found with respect to frequency of adverse effects. Both par- No difference with respect to pain was demonstrated between in-
ticipants and outcome assessment were blinded in this trial, the tra-articular steroid injection versus physiotherapy and NSAID at
method of analysis was unclear, and four patients (12.5%) dropped two and 12 weeks following treatment in one trial of 20 partici-
out of the low-dose group. pants (Arslan 2001). However participants were unblinded in this
INTRA-ARTICULAR STEROID INJECTION FOR ADHE- study and it was unclear whether outcome assessment was blinded.
SIVE CAPSULITIS: COMPARISON OF ANTERIOR TO INTRA-ARTICULAR STEROID INJECTION VERSUS CAP-
POSTERIOR APPROACH SULAR DISTENSION WITH AIR FOR ADHESIVE CAP-
The one trial (involving 40 participants) that compared anterior SULITIS
to posterior intra-articular steroid injection for adhesive capsulitis No difference with respect to improvement in abduction at 16
did not provide any comparative data, although reported a signifi- weeks was found in one trial of 29 participants comparing intra-
cantly higher level of injection accuracy with the anterior approach articular steroid injection to capsular distension with air for ad-
(19/20, 95% versus 10/20 50%, p < 0.02) (White 1996). hesive capsulitis (Jacobs 1991). In this trial outcome assessment
INTRA-ARTICULAR STEROID INJECTION VERSUS was blinded but it was unclear whether participants were blinded.
PHYSIOTHERAPY FOR ADHESIVE CAPSULITIS There was no loss to follow up reported and an intention to treat

Corticosteroid injections for shoulder pain (Review) 8

Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
analysis was performed. acromial steroid injection and NSAID in improvement in global
INTRA- assessment score at six weeks (White 1986).
ARTICULAR STEROID INJECTION VERSUS CAPSULAR INTRA-ARTICULAR, SUB-ACROMIAL AND ACROMIO-
DISTENSION WITH LIGNOCAINE AND STEROID FOR CLAVICULAR STEROID INJECTIONS VERSUS PHYS-
ADHESIVE CAPSULITIS IOTHERAPY (NOT MANIPULATION) FOR GENERAL
The one trial (involving 22 participants) that compared intra- SHOULDER PAIN (MIXED DIAGNOSES)
articular steroid injection to capsular distension with lignocaine A benefit favouring steroid injections over physiotherapy (not ma-
and steroid did not provide sufficient data for meta-analysis (Gam nipulation) with respect to pain at the end of treatment (when
1998). They reported a benefit favouring the capsular distension patient left study or 11 weeks post-randomisation) was demon-
group with respect to range of movement and analgesic use, no strated in one trial of 82 participants with general shoulder pain
difference with respect to pain at rest but a trend favouring the (mixed diagnoses)(WMD -2.30, 95% CI -4.10, -0.50) (Winters
distension group for pain with activity (double-blind, one patient 1997).
in each group lost to follow-up, completers analysis only). INTRA-ARTICULAR, SUB-ACROMIAL AND ACROMIO-
INTRA-ARTICULAR STEROID INJECTION CLAVICULAR STEROID INJECTIONS VERSUS MANIPU-
VERSUS STELLATE GANGLION BLOCK FOR ADHESIVE LATION FOR GENERAL SHOULDER PAIN (MIXED DI-
CAPSULITIS AGNOSES)
The one trial (involving an unknown number of participants) A benefit favouring steroid injections over manipulation with re-
that compared intra-articular steroid injection to stellate ganglion spect to pain at the end of treatment (when patient left study or
block for adhesive capsulitis did not provide sufficient data for 11 weeks post-randomisation) was demonstrated in one trial of 77
meta-analysis (Williams 1975). It reported no differences in out- participants with general shoulder pain (mixed diagnoses)(WMD
come between treatment groups at four weeks and three months. -3.40, 95% CI -5.46, -1.34) (Winters 1997).
INTRA-ARTICULAR STEROID INJECTION VERSUS UL- INTRA-AR-
TRASOUND FOR ROTATOR CUFF DISEASE TICULAR STEROID INJECTION AND NON-STEROIDAL
No difference with respect to pain, range of abduction or success ANTI-INFLAMMATORY MEDICATION (NSAID) VERSUS
of therapy at four weeks was found in one trial of 24 participants PLACEBO FOR ROTATOR CUFF DISEASE
comparing intra-articular steroid injection to ultrasound for rota- No difference with respect to pain or success of therapy at four
tor cuff disease (Berry 1980). weeks was found in one trial of 24 participants comparing intra-
INTRA-ARTICULAR STEROID INJECTION VERSUS articular steroid injection and NSAID to placebo for rotator cuff
ACUPUNCTURE FOR ROTATOR CUFF DISEASE disease and range of abduction at four weeks favoured the placebo
No difference with respect to pain, range of abduction or success group (WMD -27.60, 95% CI -49.99, -5.21) (Berry 1980).
of therapy at four weeks was found in one trial of 24 participants INTRA-ARTICULAR STEROID INJECTION AND MANIP-
comparing intra-articular steroid injection to acupuncture for ro- ULATION UNDER ANAESTHESIA VERSUS MANIPULA-
tator cuff disease (Berry 1980). TION UNDER ANAESTHESIA ALONE FOR ADHESIVE
CAPSULITIS
INTRA-ARTICULAR STEROID One trial of 24 participants demonstrated no difference with re-
INJECTION VERSUS HYALURONATE INJECTION FOR spect to range of abduction at four months between participants
FULL THICKNESS ROTATOR CUFF TEAR who had received an intra-articular injection of steroid with ma-
No difference with respect to satisfaction with treatment at 4 weeks nipulation under anaesthesia compared to those who had manip-
was found in one trial of 78 participants comparing intra-articular ulation under anaesthesia alone (Kivimcki 2001).
steroid injection to hyaluronate injection for full thickness rotator SUB-ACROMIAL
cuff tears (Shibata 2001). STEROID INJECTION AND NON-STEROIDAL ANTI-IN-
SUB-ACROMIAL STEROID FLAMMATORY MEDICATION (NSAID) VERSUS NSAID
INJECTION VERSUS NON-STEROIDAL ANTI-INFLAM- ALONE FOR ROTATOR CUFF DISEASE
MATORY MEDICATION (NSAID) FOR ROTATOR CUFF There was no added benefit of subacromial steroid injection over
DISEASE NSAID alone in one trial of 50 participants with respect to im-
The results of three trials with a total of 120 participants with provement in pain, function, range of abduction and remission at
rotator cuff disease that compared subacromial steroid injection to four weeks (Petri 1987).
NSAID could be pooled (Adebajo 1990, Petri 1987, White 1986) INTRA-ARTICULAR AND SUB-ACROMIAL STEROID IN-
(comparison 11). No benefit of subacromial steroid injection over JECTION VERSUS PLACEBO FOR SHOULDER PAIN
NSAID with respect to improvement in pain, function or range (MIXED DIAGNOSES)
of shoulder abduction at four or six weeks was demonstrated. One The one trial (involving 101 participants) that compared a com-
of the trials also failed to demonstrate any difference between sub- bination of both intra-articular and sub-acromial steroid injection

Corticosteroid injections for shoulder pain (Review) 9

Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
to placebo for shoulder pain (mixed diagnoses) did not provide placement of subacromial steroid injection, no trials have com-
sufficient data for meta-analysis (Richardson 1975). It reported pared blind injection to radiologically-guided injection with re-
a trend towards the steroid injections being more effective than spect to outcome.
placebo at two and six weeks (double-blind, unclear if completers
For adhesive capsulitis, we were unable to pool the results of any
only analysis and loss to follow-up was 16 and 13% in the steroid
trials comparing intra-articular steroid alone or in combination
injections and placebo groups respectively).
with subacromial steroid injection to placebo or no treatment.
SUPRASPINATUS INJECTION VERSUS PLACEBO FOR
Two trials suggested a possible early benefit and none of the trials
ROTATOR CUFF DISEASE (SUPRASPINATUS TENDINI-
demonstrated any longer term benefit. One trial did demonstrate a
TIS)
trend favouring higher dose over lower dose intra-articular steroid
The single trial that compared supraspinatus steroid injection
injection for pain improvement at six weeks in adhesive capsulitis
to placebo for rotator cuff disease (supraspinatus tendinitis)(25
although there were no differences with respect to improvement
participants) did not provide sufficient data for meta-analysis
in sleep disturbance, functional impairment or improvement in
(Withrington 1985). It reported no difference with respect to pain
external rotation. One trial suggested that the anterior approach
or analgesics consumption at two and eight weeks follow up.
may be more accurate but no trials have compared the efficacy of
anterior versus posterior intra-articular injection. No trials have
compared blind injection to radiologically-guided injection with
respect to outcome although one trial found no benefit of injec-
DISCUSSION tion around the anterior shoulder joint versus placebo and one
trial demonstrated that anatomical steroid injection may be supe-
This review specifically sought to determine the evidence for effi-
rior to trigger or tender point injection with respect to success rate
cacy of corticosteroid injections for shoulder pain. Despite a lack
after one week for general shoulder pain. One trial did demon-
of uniformity in the way shoulder disorders are labelled and de-
strate that intra-articular steroid injection is more beneficial than
fined we broadly categorised the trial populations into adhesive
physiotherapy in terms of pain, functional disability and range of
capsulitis, rotator cuff disease, full thickness rotator cuff tear and
abduction at three and seven weeks, although this benefit was no
a mixed population of patients with shoulder pain based upon
longer apparent by 26 and 52 weeks. While this was supported by
the information provided in the trials. Nevertheless the degree to
one trial that compared a combination of intra-articular and sub-
which the results of different trials could be compared and/ or
acromial steroid injection to physiotherapy, another trial found
pooled was still limited particularly by the heterogeneity of the
no difference between steroid injection versus physiotherapy and
interventions and comparisons studied, varying methodological
NSAID. One trial suggested that distension of the shoulder joint
quality, inadequate reporting of results and small sample sizes.
with steroid and lignocaine conferred a benefit over steroid injec-
For rotator cuff disease, the pooled results of two small studies sug- tion alone with respect to range of movement and pain with activ-
gested a small benefit of subacromial steroid injection over placebo ity but not pain at rest whereas another trial reported no difference
measured at four weeks. However the results of five further trials, in abduction when steroid injection was compared to distension
of varying methodological quality, that were unable to be pooled of the shoulder joint with air alone. Finally one trial demonstrated
reported varying results (benefit favouring steroid injection in two no additional benefit of intra-articular steroid injection over ma-
trials, no difference in two trials and benefit favouring placebo nipulation under anaesthesia alone. Based upon the findings of
in one trial). In addition, the pooled results of three trials found these studies, it is difficult to draw any firm conclusions about the
no difference in outcome between subacromial steroid injection value of intra-articular steroid injection for adhesive capsulitis.
and NSAID; one trial found no additional benefit of subacro-
We were able to locate only one trial that specifically studied the
mial steroid injection over NSAID alone; one trial reported no
value of steroid injection for full thickness rotator cuff tear. It
difference in outcome between intra-articular steroid injection,
reported no difference in outcome between those who received
placebo, ultrasound and acupuncture; and one trial reported no
intra-articular steroid versus those who received hyaluronate at
difference in outcome between supraspinatus injection of steroid
four weeks. With the increasing availability of ultrasound and MR
and placebo. Based upon these findings, it is difficult to draw any
imaging, it should be possible to perform trials investigating the
firm conclusions about the short- or long-term benefit of sub-
efficacy of other interventions for this subset of patients.
acromial steroid injection for rotator cuff disease. It is not known
whether benefit is dependent upon accurate placement of steroid Two previous reviews of steroid injections for shoulder pain (Van
into the subacromial space although one trial which included a Der Heijden 1996) and for rotator cuff tendinitis (Goupille 1996)
general population of patients with shoulder pain demonstrated have been performed. Goupille and Sibilia concluded that steroid
that anatomical steroid injection may be superior to trigger or ten- injection is effective in the treatment of rotator cuff tendinitis.
der point injection with respect to success rate after one week for However, this conclusion cannot be verified by the presented re-
general shoulder pain. While two studies have verified accurate sults. Their review included non-randomized studies, reported re-

Corticosteroid injections for shoulder pain (Review) 10

Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
sults of primary studies only as significant or not significant and issues include the importance of accurate placement of the injec-
they made no attempt to quantify effect sizes or pool results. We tion, the frequency, dose and type of steroid injected and choice
verified the conclusions of the review by Van Der Heijden et al re- of comparator.
garding the overall poor methodological quality of reviewed trials,
however our review differs in several important respects. Firstly,
we attempted to differentiate studies based upon the nature of the AUTHORS CONCLUSIONS
populations being studied, recognizing that the benefits of therapy
may vary for different underlying causes of shoulder pain. Sec- Implications for practice
ondly, we calculated effect sizes for the same reported outcome
measures in different trials. This enables a direct comparison be- There is little evidence to either support or refute the efficacy of
tween studies using the same outcome measurement, although it steroid injections for shoulder pain. While there are many ran-
is important to note that if one effect size is larger than another it domised controlled trials of corticosteroid injections for shoulder
may be because in the different studies, the numerator (the treat- pain, their small sample sizes, variable methodological quality and
ment effect) is larger, the denominator (the variability between heterogeneity in terms of population studied, injection modality
subjects in each group) is smaller, or some combination of the employed and choice of comparator results in little overall evi-
two. In the previous studies, the overall efficacy of interventions dence to guide treatment. There is evidence to support the use
was compared based upon calculation of success rates for each in- of subacromial corticosteroid injection for rotator cuff disease al-
tervention group. These were determined by dividing the number though its effect may be small and not well-maintained, and it
of documented successes (defined as recovery or substantial im- may be no better than NSAID. There is a suggestion that intra-
provement from baseline, according to the patient) at the end of articular steroid injection may be beneficial in the short-term for
the intervention period by the number allocated to the interven- adhesive capsulitis but again the effect may be small and not well-
tion by randomization. The exact definition of success therefore maintained.
differed between papers and is, in essence, subjective. Both previ-
ous reviews did not attempt to pool the results of different trials Implications for research
because of valid concerns regarding the biased conclusions that There is a need for further trials investigating the efficacy of cor-
may be drawn when combining studies of poor methodological ticosteroid injections for shoulder pain. Further work in needed
quality. However, we pooled the results of the two steroid injection in developing standard criteria to define shoulder disorders and a
studies that received the highest methodological ranking in their minimum core set of outcome measures. Other important issues
reviews, adding further weight to the conclusions of our review. that remain to be clarified include whether the accuracy of needle
placement, anatomical site, frequency, dose and type of corticos-
teroid influences efficacy.
This updated review of steroid injections for shoulder pain has
again highlighted issues that need to be considered in order to
determine the value of this intervention for shoulder pain. Less
than half of the 26 trials that fulfilled inclusion criteria contained
ACKNOWLEDGEMENTS
sufficient data for meta-analysis (12/26, 46.2%) and data from
only three trials, included in our original review, could be pooled. We are grateful to the Australasian Cochrane Centre and the
Further work is needed in developing standard criteria to define Cochrane Musculoskeletal Review Group for their methodologi-
shoulder disorders and a minimum core set of outcome measures cal support and to Anita Gross and Jeff Harris for acting as external
that should be used in all clinical trials of shoulder pain. Other reviewers for this review.

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corticosteroid versus indomethacin therapy. J Rheumatol

Kivimcki J, Pohjolainen T. Manipulation under
1986;13:608613.
anaesthesia for frozen shoulder with and without steroid
injection. Arch Phys Med Rehabil 2001;82:11881190. White 1996 {published data only}
Lee 1973 {published data only}

White AET, Tuite JD. The accuracy and efficacy of

Lee M, Haq A, Wright V, Longton E. Periarthritis of the shoulder injections in restrictive capsulitis. Journal of
shoulder: A controlled trial of physiotherapy. Physiotherapy Orthopaedic Rheumatology 1996;9:3740.
1973;59:312315. Williams 1975 {published data only}
Petri 1987 {published data only}
Williams NE, Seifert M, Cuddigan J, Wise R. Treatment

Petri M, Dobrow R, Neiman R, Whiting-OKeefe Q, of capsulitis of the shoulder. Rheum and Rehab (Abstract).
Seaman W. Randomised double blind placebo controlled 1975; Vol. 14:236.
Corticosteroid injections for shoulder pain (Review) 12
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Winters 1997 {published data only} capsulitis of the shoulder. Int J Tissue React 1998;20(4):

Winters JC, Sobel JS, Groenier KH, Arendzen HJ, 125130.
Meyboom-de-jong, B. Comparison of physiotherapy, Shanahan 200x {unpublished data only}
manipulation, and corticosteroid injection for treating Shanahan EM, Ahern M, Smith M, Wetherall M, Bresnihan
shoulder complaints in general practice: Randomized, single B, Fitzgerald O. Suprascapular nerve block in chronic
blind study. British Medical Journal 1997;314:13201325. shoulder pain.
Withrington 1985 {published data only}
Thomas 1980 {published data only}

Withrington R, Crirgis F, Seifert M. A placebo-controlled
Thomas D, Williams RA, Smith DS. [The frozen
trial of steroid injections in the treatment of supraspinatus
shoulder: A review of manipulative therapy]. Rheumatology
tendonitis. Scand J Rheum 1985;14:7678.
and Rehabiltiation 1980;19:1739.
References to studies excluded from this review Valtonen 1974 {published data only}
Valtonen E. Subacromial Betamethasone therapy. Annals
Blyth 1993 {published data only} Chirurgiae et Gynaecologiae Fenniae 1974;63(Supplement

Blyth TH, Hunter JA. Treatment of the rheumatoid 188):916.
shoulder with intra-articular steroid: comparison of superior
and anterior routes of injection. Br J Rheumatol 1993;32: Valtonen 1978 {published data only}
69. Valtonen E. Double acting betamethasone in the treatment
of supraspinatus tendinitis. J Int Med Res 1978;6:463467.
Corbeil 1992 {published data only}

Corbeil V, Dussault RG, Leduc BE, Fleury J. Adhesive Weiss 1978 {published data only}
capsulitis of the shoulder: comparative study of distensive Weiss JJ, Ting M. Arthrography-Assisted Intra-articular
and nondistensive arthrography in combination with intra- Injection of Steroids in Treatment of Adhesive Capsulitis.
articular steroid injection [Capsulite rtractile de lpaule: Arch Phys Med Rehab 1978;59:285287.
tude comparative de larthrographie avec corticothrapie
intraarticulaire avec ou sans distension capsulaire]. Additional references
Canadian Association of Radiologists Journal 1992;43(2):
12730. Chakravarty 1993
Chakravarty K, Webley M. Shoulder Joint Movement and
Gado 1996 {published data only}
Its Relationship to Disability in the Elderly. J Rheumatol

Gado K, Emery P. Intra-articular guanethidine injection
1993;20:135961.
for resistant shoulder pain: A preliminary double-blind
study of a novel approach. Annals of Rheumatic Diseases Chard 1991
1996;55:199201. Chard MD, Hazleman R, Hazleman BL, King RH, Reiss
Hardy 1986 {published data only} BB. Shoulder disorders in the elderly: a community survey.

Hardy D, Vogler J, White R. The shoulder impingement Arthritis Rheum 1991;34:766769.
syndrome: Prevalence of Radiographic findings and Clarke 2000
Correlation with response to therapy. Am J Roentgenology Clarke M, Oxman AD, editors. Cochrane Reviewers
1986;147(3):557561. Handbook 4.1. Version 4.1. Oxford: The Cochrane
Lloyd-Roberts 1959 {published data only} Collaboration, 2000.

Lloyd-Roberts GC, French PR. Periarthritis of the Croft 1996
shoulder. A study of the disease and its treatment. British Croft P, Pope D, Silman A. The clinical course of shoulder
Medical Journal 1959;2:15691571. pain: prospective cohort study in primary care. BMJ 1996;
Mardjuadi 1978 {published data only} 313:6012.

Mardjuadi A, Dequeker J. Double-blind trial comparing Deeks 1998
bufexamac infiltrations with triamcinolone acetonide Deeks J. Odds ratios should be used only in case-control
infiltrations in patients with periarthritis of the shoulder. studies and logistic regression analysis (letter). BMJ 1998;
Current Medical Research and Opinion 1978;5(5):401405. 317:317.
Murnaghan 1955 {published data only} Goupille 1996

Murnaghan G, McIntosh D. Hydrocortisone in painful Goupille P, Sibilia J. Local corticosteroid injections in
shoulder. A controlled trial. The Lancet 1955:798800. the treatment of rotator cuff tendinitis (except for frozen
Quin 1965 {published data only} shoulder and calcific tendinitis).. Clin Exp Rhematol 1996;

Quin CE. Frozen shoulder: Evaluation of treatment with 14(5):5616.
hydrocortisone injections and exercises. Ann Phys Med Green 1998a
1965;8:2229. Green S, Buchbinder R, Forbes A, Glazier R. Interventions
Rovetta 1998 {published data only} for shoulder pain (Cochrane Review). Cochrane Database

Rovetta G, Monteforte P. Intraarticular injection of of Systematic Reviews 2002, Issue 4.[Art. No.: CD001156.
sodium hyaluronate plus steroid versus steroid in adhesive DOI: 10.1002/14651858.CD001156.pub2]
Corticosteroid injections for shoulder pain (Review) 13
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Green 1998b Rekola 1993
Green S, Buchbinder R, Forbes A, Glazier R. Systematic Rekola KE, Keinanen-Kiukaanniemi S, Takala J. Use of
review of randomised controlled trials of interventions for primary health services in sparsley populated country
painful shoulder: selection criteria, outcome assessment, districts by patients with musculoskeletal symptoms:
and efficacy. BMJ 1998;16:35460. consultations with a physician. J Epidemiol Commumity
Juni 1999 Health 1993;47:153157.
Juni P, Witschi A, Bloch R, Egger M. The hazards of scoring Van Der Heijden 1996
the quality of clinical trials for meta-analysis. JAMA 1999; Van Der Heijden GJMG, Van Der Windt DAWM,
282(11):105460. Kleijnen J, Koes B, Bouter L. Steroid injections for shoulder
Lundberg 1969 disorders: a systematic review of randomised clinical trials.
Lundberg B. The frozen shoulder. Acta Orthopaedica Br J Gen Pract 1996;46:30916.
Scandinavia 1969;Suppl 119.
Indicates the major publication for the study

Corticosteroid injections for shoulder pain (Review) 14

Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
CHARACTERISTICS OF STUDIES

Characteristics of included studies [ordered by study ID]

Adebajo 1990

Methods Randomised, controlled trial.

Blinding: both participants and outcome assessors were blinded.
Loss to follow-up: 0 patients
Appropriate statistical analysis: yes, intention to treat analysis

Participants 60 patients.
Inclusion criteria: symptoms less than 3 months and rotator cuff tendonitis according to Cyriaxs criteria:
1. pain exacerbated by: resisted movement: on abduction (supraspinatus tendinitis) with a painful arc; on
external rotation (infraspinatus tendinitis)
2. active range frequently limited by pain and passive range always > active range of movement
3. normal glenohumeral range of passive movement
Exclusion criteria: Systemic inflammatory arthropathy; recent peptic ulceration or gastrointestinal bleeding
or sensitivity to NSAID or triamcinolone; shoulder injection within previous 3 months; glenohumeral
arthritis, acromioclavicular arthritis, bicipital tendinitis or a suspected rotator cuff tear (weak arm elevation,
positive drop arm sign or a high riding humerus seen radiologically); local infection.
NSAIDs stopped at least one week before study entry.

Interventions Group 1(20 patients): 50 mg diclofenac 3 times a day for 28 days + subacromial injection of 3ml of 0.
5% lignocaine
Group 2 (20 patients): diclofenac placebo tablets + subacromial injection of 2ml 0.5% lignocaine & 1ml
of 80mg/ml triamcinolone hexacetomide.
Group 3 (20 patients): diclofenac placebo tablets + subacromial injection of 3ml 0.5% lignocaine.
All patients instructed in pendulum and wall climbing exercises to perform at home

Outcomes Outcome assessed at baseline and 4 weeks

1) Overall pain severity assessed by 10cm VAS (0 = no pain, 10 = severe pain)
2) Limitation of function on 4-point scale (0 = no 1 = mild, 2 = moderate and 3 = severe limitation of
function respectively)
3) Range of active and passive shoulder movement measured to the nearest 5 degrees with a pendulum
goniometer

Notes See analyses 2, 11.

Standard error of means converted to standard deviations.

Risk of bias

Item Authors judgement Description

Allocation concealment? Yes A - Adequate

Corticosteroid injections for shoulder pain (Review) 15

Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Arslan 2001

Methods Randomised controlled trial.

Blinding: participants were not blinded. Unclear if outcome assessment was blinded.
Loss to follow-up: None reported.
Appropriate statistical analysis:appears to be intention to treat analysis

Participants 20 patients.
Inclusion criteria:
1. Total range of motion less than 50% of normal range
2. No previous injections in the involved shoulder
3. No history of allergy to local anesthetics or steroids
4. Absence of coagulation diseases
5. Absence of polyarthritis or neurological diseases that may lead to shoulder pain
Exclusion criteria: significant glenohumeral arthritis, cervical radiculopathy, stroke, suspected rotator cuff
tear, bicipital tendinitis, in receipt of anticoagulants or non-steroidal anti-inflammatory drugs

Interventions Group1 (10 patients): intra-articular injection of 40mg methylprednisolone acetate (1ml) with 1ml 2%
lidocaine
Group 2 (10 patients): physiotherapy (hot pack application for 20 minutes, ultrasonic therapy at 3.5 W/
cm2 for 5 minutes, and passive glenohumeral joint stretching exercises to the patients tolerance, followed
by Codman exercises and wall climbing) and a nonsteroidal anti-inflammatory drug (acemethazine 120
mg/day). Unclear how many physiotherapy sessions were given.
All patients received same home exercise program.

Outcomes Outcome assessed at baseline, 2 and 12 weeks

1) pain severity using a VAS
2) range of motion using a goniometer

Notes See analyses 6.

No measures of variance reported for range of motion so only pain considered in meta-analysis

Risk of bias

Item Authors judgement Description

Allocation concealment? Unclear B - Unclear

Berry 1980

Methods Randomised, controlled trial.

Blinding: Blinded outcome assessor, participants blinded to some treatments only.
Loss to follow-up: none
Appropriate statistical analysis: appears to be intention to treat analysis

Participants 60 patients. Inclusion criteria: rotator-cuff lesion defined as pain on resisted movements of the shoulder
with loss of passive movement, mainly abduction.
Exclusion criteria included: frozen shoulder (not defined); fracture; inflammatory arthritis

Corticosteroid injections for shoulder pain (Review) 16

Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Berry 1980 (Continued)

Interventions 12 patients in each group

Group 1: 400mg tolmetin sodium 3x day plus anterior injection 40mg methyl prednisolone with 2ml
2% lignocaine.
Group 2: placebo tolmetin sodium 3x day plus injection as above
Group 3: acupuncture once per week
Group 4: physiotherapy in form of ultrasound (8 sessions of 10min)
Group 5: placebo tolmetin sodium plus placebo ultrasound.

Outcomes Assessed at baseline, 2, 4 weeks

1) Pain using a 100mm VAS.
2) Pain using a 4- point scale (none, mild, moderate and severe).
3) Shoulder abduction using a goniometer.
4) Comparative assessment by patient and assessor scored as much better, better, same, worse, much
worse.
5) Success or failure at end of 4 weeks, defined in the opinion of the assessor as the need for a steroid
injection.
6) Adverse effects

Notes See analyses 1, 8, 9, 14.

Comparison of steroid injection plus NSAID versus steroid injection alone is included in NSAID review

Risk of bias

Item Authors judgement Description

Allocation concealment? Unclear B - Unclear

Blair 1996

Methods Randomised, controlled trial. Blinding: both participants and

outcome assessors were blinded.
Loss to follow-up: Cant tell
Appropriate statisticial analysis: unclear

Participants 40 patients.
Inclusion criteria:
1. at least 3 months of symptoms
2. diagnosis of subacromial impingement syndrome on the basis of the lidocaine injection test
3. no previous subacromial corticosteroid injections
4. no evidence of os acromiale on plain X-Ray
5. not involved in workers compensation claim related to the shoulder
6. no clinical or radiographic evidence of full thickness rotator cuff tear

Interventions Group 1(21 patients): 6ml of 1% lidocaine without epinephrine.

Group 2 (19 patients): 2ml containing 40 mg of triamcinolone acetonide per ml with 4 ml of 1% lidocaine
without epinephrine.
All patients underwent a standardized program of physiotherapy

Corticosteroid injections for shoulder pain (Review) 17

Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Blair 1996 (Continued)

Outcomes Assessed at baseline and every 4 weeks until completion of study (not defined) - (mean duration of
follow up was 33 weeks (range: 12-55) and 28 weeks (range: 12-52) in corticosteroid and placebo groups
respectively).
1. Performance of 5 activities of daily living (ability to use back pocket, wash opposite axilla, eat with
utensils, wash or comb hair, perform toilet functions). Assessed by outcome assessor. Three-point scale
for each item (0=unable to do, 1 -with difficulty, 2- without difficulty). Mean overall score out of 10
2. Overall subjective assessment of pain on 4 point scale (0=no, 1=mild, 2=moderate, 3=severe pain) and
whether pain was decreased, unchanged or worse compared to before the injection.
3. Detailed physical examination documenting muscle atrophy, areas of localised tenderness, ROM using
a goniometer (forward flexion, external rotation and internal rotation), presence of impingement (as
described by Neer)

Notes Met inclusion criteria for review, however the exact timing of comparisons between groups is not provided
(most recent follow-up), and no measure of variance reported and no means of calculating it. Therefore
not included in the meta-analysis.
Results:
At the most recent follow-up evaluation, at a mean of 33 weeks in corticosteroid group and 28 weeks
in placebo group, the corticosteroid group was significantly better with respect to pain and range of
motion but there was no significant difference between the two groups with respect to improvement in
performance of activities of daily living

Risk of bias

Item Authors judgement Description

Allocation concealment? Unclear B - Unclear

Bulgen 1984

Methods Randomised trial

Blinding: outcome assessment was blinded. Participants do not appear to have been blinded.
Loss to follow-
up: unclear (see notes)
Appropriate statistical analysis: unclear (see notes)

Participants 42 patients
Inclusion criteria: frozen shoulder: pain in shoulder for at least 1 month, sleep disturbance due to night
pain,
inability to lie on affected side,
restriction of active and passive shoulder movements,
restriction in external rotation of at least 50%
Exclusion criteria: sensory symptoms or signs in the affected arm or radiation of pain to the neck,
generalised arthritis, fractures or dislocations of humerus, cervical spondylosis, evidence of referred pain

Interventions Group 1(11 patients): intra-articular steroid injection by anterior route

Group 2 (11 patients): mobilisation
Group 3(12 patients): ice therapy
Group 4(8 patients): no treatment

Corticosteroid injections for shoulder pain (Review) 18

Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Bulgen 1984 (Continued)

Outcomes Assessed at baseline, weekly for 6 weeks and monthly for further 6 months 1) Night pain,
pain on movement and
rest pain during the day measured on
10cm VAS, and as better, worse, the same on follow up assessments
2) Passive movements measured to nearest 5 degrees including external rotation; total abduction, flexion
and rotation; glenohumeral abduction and flexion; hand behind back. Range of motion was reported by
recovery curves
3) Number of analgesics

Notes Met inclusion criteria for review, however no means or standard deviations reported so included in review
but not in meta-analysis. Results:
Reported little difference between groups with respect to long term outcome but some benefit with respect
to pain and range of motion in early stages with use of intra-articular steroid injection (no pain data
presented).
Another 3 patients withdrew (one after arthrogram, one received physiotherapy elsewhere and one failed
to attend). Unclear when these 3 patients withdrew and no data about them presented

Risk of bias

Item Authors judgement Description

Allocation concealment? Unclear D - Not used

Dacre 1989

Methods Randomised, controlled trial

Blinding: outcome assessment was blinded. Participants do not appear to have been blinded.
Loss to follow-up: 4 patients of unspecified group allocation (failed to attend at 6 weeks or 6 months).
Appropriate statistical analysis: Analysis based upon completers only (62/66)

Participants 66 patients. Inclusion criteria: Periarthritis

(Painful stiff shoulder for at least 4 weeks, inability to use the affected arm with restriction of movement
and loss of full function,
pain at night causing sleep disturbance with inability to lie on the affected side.
Exclusion criteria: stroke, generalised arthritis, cervical spondylosis, highly localised lesion such as bicipital
tendinitis

Interventions Group 1(22 patients): Local steroid injections of 20mg triamcinolone with 1 ml 2% lignocaine injected
anteriorly around the shoulder joint by 1 physician.
Group 2(20 patients): Four to six weeks of physiotherapy thought most appropriate, performed by one
therapist and mainly comprised of mobilisation.
Group 3(20 patients): Both physiotherapy and injection as above

Outcomes Outcome assessed at baseline, six weeks and six months

1) Day pain, night pain and pain during active and passive movement each assessed on 10cm VAS.
2) Range of passive movement: complete shoulder abduction, glenohumeral abduction and external
rotation measured with goniometer; passive internal rotation measured by hand behind back.

Corticosteroid injections for shoulder pain (Review) 19

Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Dacre 1989 (Continued)

3) Treatment costs.

Notes While included in review, data presented with no measure of variance and no means of calculating it.
Therefore not included in the meta-analysis.
Results:
All groups demonstrated improvement in pain at six weeks, but with no significant differences between
groups

Risk of bias

Item Authors judgement Description

Allocation concealment? Unclear B - Unclear

de Jong 1998

Methods Randomised controlled trial.

Blinding: Both participants and outcome assessors were blinded. Loss to follow-up: 4 patients (12.5%)
in low-dose (10mg) group and 1 patient (4%) in high-dose (40mg) group.
Appropriate statistical analysis: Cant tell

Participants 57 patients.
Inclusion criteria: Adhesive capsulitis based upon following criteria:
1) pain in shoulder and arm, either of spontaneous onset, or precipitated by a relatively minor trauma. 2)
restriction of passive movement of glenohumeral joint according to capsular pattern with greater than 45
degrees restriction of passive external rotation
3) waking at night due to pain when lying on affected shoulder
4) no clinical or radiological evidence of other pathology which could account for similar symptoms.
Exclusion criteria: evidence of cervical radiculopathy, paresis or other neurological changes in the upper
limb on involved side, insulin
dependent diabetes.

Interventions Group 1(32 patients): 3 intra-articular injections of 10mg triamcinolone actonide.

Group 2 (25 patients): 3 intra-articular injections of 40mg of triamcinolone actonide. One week between
first and second injections and two weeks between second and third injections. Patients received no other
treatments and were instructed to use the shoulder and arm normally within the limits of pain

Outcomes Assessed at baseline, 1 week, 3 and 6 weeks after initial injection.

1) Pain intensity scored on VAS ranging from 0 = no pain to 100 = maximal pain.
2) Disturbance of sleep at night scored by patient on 4-point ordinal scale.
3) Impairment of ability to use the shoulder and arm, scored by patient on 4-point ordinal scale.
4) Restriction of range of passive glenohumeral movement. External rotation was measured with simple
goniometer and scored on 4-point scale where 0 = no restriction; 1 = restriction of less than 45 degrees; 2
= more than 45 degrees but less than 60 degrees; 3 = restriction of more than 60 degrees

Notes See analyses 4

Risk of bias

Corticosteroid injections for shoulder pain (Review) 20

Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
de Jong 1998 (Continued)

Item Authors judgement Description

Allocation concealment? Yes A - Adequate

Gam 1998

Methods Randomised controlled trial.

Blinding: both participants and outcome assessors were blinded.
Loss to follow-up: 1 patient (11.1%) in steroid alone group and 1 patient (7.7%) in steroid + distension
group.
Appropriate statistical analysis: Based upon completers only analysis (20/22)

Participants 22 patients.
Inclusion criteria:
1) age between 18 and 70 yrs; 2) frozen shoulder of more than 6 weeks duration; 3) nocturnal accentuation
of pain; 4) passive range of external rotation in shoulder less than 50% of opposite shoulder; 5) no effusion
in glenohumeral joint; 6) normal x-ray of affected shoulder; 7) normal ESR, haemoglobin, leucocytes,
alkalic phosphates and negative IgM rheumatoid factor; 8) no trauma to shoulder in last 6 months that
caused pain or restricted movement of the shoulder within one week (acceptance of trivial minor injuries)
; 9) no diabetes; 10) no other treatment for frozen shoulder except analgesics in study period

Interventions Group 1(13 patients): distension with 19ml of 0.5% lidocaine and 20mg triamcinolone hexacetonid.
Group 2 (9 patients): 20mg triamcinolone hexacetonid injection alone.
The intraarticular injection in the glenohumeral joint was carried out by a posterior approach and con-
firmed by ultrasound.
The treatment was repeated once a week for a maximum of 6 weeks or until no symptoms

Outcomes Assessed at baseline, 3, 6 and 12 weeks.

1) physician judgement of severity of disorder (severe = 1, moderate = 2, light pain = 3) from patients
verbal expression of pain and function (undressing);
2) passive flexion, extension, abduction, external rotation, and elevation of affected shoulder in comparison
with opposite shoulder (i.e. 0-25% = 1, 25-50% = 2, 50-75% = 3, 75-100% = 4). Elevation performed
with fixed scapulae;
3) Pain at rest and on function using VAS (where 0 = no pain and 10 = unbearable pain). Patients recorded
their average pain every day in study period and mean score of each week was used for evaluations; 4)
Daily usage of analgesics;
5) type and number of side effects.

Notes This article met the inclusion criteria for this review but the data was not presented in a format which
allowed meta-analysis.
Randomisation according to the envelope method.
Results:
Signficant improvement in range of motion and analgesic use in group treated with distension with local
anesthetis and steroid vs steroid alone. There was no difference in pain at rest but a trend favouring the
distension group for pain with activity

Risk of bias

Corticosteroid injections for shoulder pain (Review) 21

Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Gam 1998 (Continued)

Item Authors judgement Description

Allocation concealment? Unclear B - Unclear

Hollingworth 1983

Methods Randomised controlled trial

Blinding: both participants and outcome assessors were blinded
Loss to follow-up: none reported
Appropriate statistical analysis: yes, intention to treat.

Participants 77 patients
Inclusion criteria: diagnosis of pain of soft tissue origin, shoulder or upper arm pain of any duration
and of spontaneous or traumatic origin, positive signs on selective tissue tension examination of shoulder
structures classified on basis of clinical criteria as:
1. Supraspinatus tendonitis
2. Infraspinatus tendonitis
3. Subscapularis tendonitis
4. Bursitis
5. A.C. joint sprain
6. Capsulitis.
Exclusion criteria: patients with predominantly neck pain, paraesthesiae or neurological signs in arms or
hands, specific arthritis (septic, gout, pseudogout), polyarthritis and generalised disease relevent to the
symptoms, radiological evidence of osteoarthritis or other bone disease, overt or predominant psychological
overlay

Interventions Group 1(38 patients): Tender or trigger point injection of 2ml, 40 mg methylprednisolone acetate mixed
with 1% lignocaine. The most tender point which reproduced the patients pain was identified by deep
palpation.
Group 2 (39 patients): Functional injection, the site of the injection being the anatomical area (ie rotator
cuff tendon, subacromial bursa) indicated by the selective tissue tension examination. The same injection
solution was used.
At one week, if the pain had not cleared completely or considerably diminished, the alternative (cross over)
injection was given. If the crossover injection was not effective after one week then the original injection
was given again (recrossover)

Outcomes Assessed at baseline, 1, 4 weeks. Success defined as reduction in pain from severe to mild or nil, with
corresponding clearing of signs on objective examination

Notes Patients randomly assigned to treatment group by physician giving the injections.
Crossover and recrossovers after one and two weeks as per protocol. Only 1 week data included in review
- see analyses 3. Ten of the successes at 1 week had a different pattern of pain at one week. All patients
who were considered success at 1 week maintained their relief at 4 and 8 weeks apart for the 5 patients
who presented with new injuries or spontaneous recurrences

Risk of bias

Corticosteroid injections for shoulder pain (Review) 22

Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Hollingworth 1983 (Continued)

Item Authors judgement Description

Allocation concealment? No C - Inadequate

Jacobs 1991

Methods Randomised controlled trial.

Blinding: Outcome assessment was blinded. Unclear if patients were blinded.
Loss to follow-up: none reported
Appropriate statistical analysis: Yes, appears to be intention to treat analysis

Participants 47 patients.
Inclusion criteria: capsulitis of the shoulder defined by abduction and forward flexion of less than 90
degrees, external rotation less than 20 degrees, an intact rotator cuff clinically and normal shoulder
radiographs

Interventions Group 1(14 patients): shoulder distension with air (6ml 0.25% bupivacaine + 3ml air = 9ml total)
Group 2 (15 patients): intra-articular steroid injection (40mg triamcinolone acetonide in 1ml injection)
Group 3 (18 patients): distension with air and steroid (40mg triamcinolone acetonide in 1ml + 6ml 0.
25% bupivacaine + 3ml air = 10ml total)

Outcomes Assessment at baseline, 6, 12 and 16 weeks.

1) Analgesic use
2) severity of pain in relation to daily activities (on a 6-point scale from 0=none to 5 = severe, interferes
with sleep)
3) severity of pain with resisted shoulder movement (on a 4-point scale from 0 = none to 3 = severe, with
pain inhibition)
4) range of active and passive abduction and forward flexion using a hydrogoniometer and external rotation
of the shoulder according to Cyriax method
5) strength using a isokinetic shoulder dynanometer

Notes Improvement in symptoms (pain was not reported separately by treatment group.
See analyses 7 for comparison of improvement in range of movement by treatment group.
Comparison of distension with air plus steroid versus steroid injection alone is included in the hydrodi-
latation review

Risk of bias

Item Authors judgement Description

Allocation concealment? Unclear B - Unclear

Corticosteroid injections for shoulder pain (Review) 23

Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Kirkley 1999

Methods Randomised controlled trial.

Blinding: both patients and outcome assessors were blinded.
Loss to follow-up: unclear
Appropriate statistical analysis: unclear

Participants 52 patients - reported on first 41 patients

Inclusion criteria:
rotator cuff tendinitis or partial rotator cuff tears who have failed to improve with non-surgical treatment.
Exclusion criteria: full thickness tear, cuff arthopathy, previous surgery, greater than one subacromial
steroid injection, injection within 3 months, inflammatory arthritis or shoulder instability

Interventions Group 1: (20 patients) 5ml subacromial injection of 2% lidocaine via posterior approach.
Group 2 (21 patients): injection as above of 4ml 2% lidocaine and 1ml 6mg betamethasone

Outcomes Assessed at baseline, 2, 6 weeks, 3, 6 months.

1) Western Ontario Rotator Cuff index (WORC)
2) American shoulder and elbow surgeons (ASES)
3) Disabilities of the Arm, Shoulder and Hand (DASH)
4) active forward elevation
5) internal and external rotation at 90 degrees of shoulder abduction
6) Neers impingement sign

Notes Abstract only - no results presented that could be used for meta-analysis.
Results showed that both groups improved compared with baseline assessment but no difference between
the two treatments

Risk of bias

Item Authors judgement Description

Allocation concealment? Unclear B - Unclear

Kivimcki 2001

Methods Randomised controlled trial.

Blinding: unable to determine whether patients and/or outcome assessors were blinded.
Loss to follow-up: 2(13%) of manipulation + steroid patients and 4(26%) of manipulation only patients
Appropriate statistical analysis: no, not intention to treat analysis, only completers (24/30)

Participants 30 patients
Inclusion criteria:
Frozen shoulder defined as: typical anamnesis and restriction of passive joint movements.
Required glenohumeral flexion < 140 degrees

Interventions Group 1(15 patients): manipulation under anaesthesia (Patients arm was first moved toward flexion while
the scapular was fixed. Thereafter, the arm was stretched in inner and outer rotation) and intra-articular
injection of 1ml betamethasone (6mg/ml) and 4ml lidocaine (10mg/ml).
Group 2 (15 patients): manipulation as above but no steroid injection

Corticosteroid injections for shoulder pain (Review) 24

Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Kivimcki 2001 (Continued)

Outcomes Assessed at baseline, 1 day, 4 months.

1) patients opinion whether the procedure had been useful, harmful, neither
2) patient evaluation of length of time shoulder pain had hindered dressing or sleeping after manipulation
3) range of passive flexion, abduction, internal and external rotation

Notes See analyses 15

Risk of bias

Item Authors judgement Description

Allocation concealment? Unclear B - Unclear

Lee 1973

Methods Randomised controlled trial

Blinding: neither patients nor outcome assessment blinded.
Loss to follow-up: not reported
Appropriate statistical analysis: no data presented.

Participants 80 patients
Inclusion criteria:
periarthritis of shoulder with pain associated with limitation of passive movement of shoulder joint
Exclusion criteria: arthritis of any kind, bone or neurological disease

Interventions Group 1(20 patients): Infra red irradiation 10 mins and exercises
Group 2(20 patients): Intra-articular hydrocortisone acetate 25mg injection via anterior approach and
exercises
Group 3(20 patients): Bicipital sheath injection of hydrocortisone acetate 25mg and exercises
Group 4(20 patients): Analgesics only

Outcomes Outcome assessed at baseline, and weekly up to 6 weeks

1) active abduction
2) passive abduction
3) active internal rotation
4) active external rotation

Notes Reported all groups improved significantly over analgesic only, with no difference between injection and
infra-red. Results presented graphically only therefore included in review but not in meta-analysis

Risk of bias

Item Authors judgement Description

Allocation concealment? Unclear B - Unclear

Corticosteroid injections for shoulder pain (Review) 25

Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Petri 1987

Methods Randomised, controlled trial

Blinding: both participants and outcome assessors were blinded.
Loss to follow-up: no loss reported
Appropriate statistical analysis: yes, intention to treat.

Participants 100 patients Inclusion criteria: Rotator cuff tendonitis defined as having at least 2 of:
1. painful abduction at any degree of motion
2. painful arc of movement from 45 to 120 degrees
3. tenderness of supraspinatus tendon insertion.
Exclusion criteria: significant glenohumeral arthritis, supraspinatus injection during preceding 3 months,
reason to suspect rotator cuff tear, contraindication to NSAIDS, allergy to lidocaine; frozen shoulder as
defined by marked restriction of both active and passive motion that did not improve with lidocaine
injection

Interventions Group 1(25 patients): 500mg naproxen 2 x day for 30 days plus subacromial bursa injection 4cc 1%
lidocaine Group 2(25 patients): 500mg naproxen 2x day for 30 days plus subacromial bursa injection of
3cc 1% lidocaine + 1cc 40mg/ml triamcinolone.
Group 3(25 patients): placebo pill 2x day for 30 days plus injection with 3cc 1% lidocaine + 1cc 40mg/
ml triamcinolone
Group 4(25 patients): placebo pill 2x day for 30 days plus injection with 4cc 1% lidocaine.
All patients received instructions in range-of-motion exercises

Outcomes Assessed at baseline, 2 and 4 weeks

1) Pain on a linear scale where 0 = worst and 5 = best
2) Patient grading of limitation of function on linear scale where 0=worst and 5=best
3) degree of active abduction
4) clinical index - 3 above factors combined, with equal weight (abduction range in degrees divided by
36) where high clinical index represents good outcome
5) remission defined as perfect score in active abduction, pain and limitation of function

Notes See analyses 2, 11, 16.

Standard error of means converted to standard deviations.

Risk of bias

Item Authors judgement Description

Allocation concealment? Yes A - Adequate

Plafki 2000

Methods Randomised controlled trial

Blinding: both participants and outcome assessors were blinded.
Loss to follow up: not reported but treatment in in Group 1 discontinued after interim analysis of first
10 patients found lack of efficacy in all patients and pain aggravation in 4 patients.
Appropriate statistical analysis: yes, intention to treat.

Corticosteroid injections for shoulder pain (Review) 26

Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Plafki 2000 (Continued)

Participants 50 patients:
Inclusion criteria: painful disabling impingement syndrome for at least 3 months duration. Diagnosis
based on patients history and positive impingement signs according to Neer and Hawkins.
Exclusion criteria: concomitant cervical cervical radiculopathy, prior subacromial corticosteroid injection,
adhesive capsulitis, full or partial-thickness rotator cuff tears, calcifying tendinitis, disorders of acromio-
clavicular joint, shoulder instability, involvement in workers compensation claims

Interventions Group 1(10 patients): 10ml injection of pure 0.5% bupivacaine

Group 2(20 patients): 10mg injection of triamcinolone acetonide (crystalline corticosteroid) with 10ml
0.5% bupivacaine
Group 3(20 patients): 4mg injection dexamethasone-21-palmitat (lipoid corticosteroid, equivalent to 2.
5mg dexamethasone) with 10 ml of 0.5% bupivacaine. All injections were into subacromial bursae with
positioning verified by ultrasound. All patients received standardized physiotherapy program consisting
of cryotherapy and active strengthening o the rotator cuff muscles

Outcomes Assessed at baseline, 1, 6 and 26 weeks

1) impingement signs
2) pain scale
3) Patte score - judges subjective estimation of pain, function, force and overall handicap (excellent when
score > 85%)
4) Ultrasound examination

Notes No data presented that could be used for meta-analysis.

Reported that favourable results were achieved in 19 out of 40 participants who received steroid injection

Risk of bias

Item Authors judgement Description

Allocation concealment? Unclear B - Unclear

Richardson 1975

Methods Randomised controlled trial

Blinding: patients and outcome assessors blinded
Loss to follow-up: 15 pateints withdrew - 9(16%) in steroid group and 6(13%) in placebo group.
Appropriate statistical analysis: unclear if completers analysis only

Participants 101 patients 1) pain on resisted abduction and/ or external rotation and/or
2) loss of passive movement of glenohumeral joint
Exclusion criteria: polymyalgia rheumatica, biceps tendonitis, as judged by pain on resisted forearm supina-
tion, polyarthritis with shoulder involvement, abnormal neurological signs or shoulder/hand syndrome,
arthritis acromioclavicualr joint as judges by joint tenderness

Interventions Group 1(54 patients): Intra-articular (1 ml) and subdeltoid bursa (1ml) steroid injection of prednisolone
acetate (single skin puncture at baseline and 2 weeks.
Group 2(47 patients): saline injection as per steroid group. Arthrogram checked placement and indicated
correct placement in subacromial bursa but not joint

Corticosteroid injections for shoulder pain (Review) 27

Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Richardson 1975 (Continued)

Outcomes Assessed at baseline, 2 and 4 weeks

1) Pain
2) Night pain
3) Pain on resisted abduction or external rotation
4) Loss of passive abduction external, and/or internal rotation.
5) At 2 and 6 weeks, degree of improvement on 5-point scale (1=worse, 2=no change, 3=slight improve-
ment, 4=definite improvement, 5=complete recovery) for pain, night pain, pain with resisted abduction
or external rotation (mean score) and loss of passive abduction, external and internal rotation (mean score)

Notes Met inclusion criteria for review, but no means or standard deviations reported.
Reported percent of patients with definite improvement or complete recovery (scores of 4 or 5) at 2 and
6 weeks but unclear if all patients included in analysis or just completers so not included in meta-analysis.
Reported a trend toward steroid injections being more effective than placebo

Risk of bias

Item Authors judgement Description

Allocation concealment? No C - Inadequate

Rizk 1991

Methods Randomised controlled trial

Blinding: both patients and outcome assessors were blinded
Loss to follow-up: Four patients withdrew before study completion: 1(6%) in lidocaine groups, 2(12%)
in intra-articular group, 1(6%) in intrabursal group.
Appropriate statistical analysis: yes, intention to treat analysis

Participants 48 patients
Inclusion criteria: Total passive range of motion < 50 percent of normal, shoulder pain less than 6 months,
pain worse at night,
no effusion in glenohumeral joint, no history of recent trauma and no previous injections in involved
shoulder, no history of allergy to local anaesthetics or steroids.
Exclusion criteria included:
polyarthritis or neurologic diseases which may lead to shoulder pain, cervical radiculopathy, evidence of
alternative cause of shoulder pain revealed in shoulder x-rays including osteoarthritis, fracture, metastases,
accromioclavicular pathology

Interventions Group 1(16 patients): intra-articular (anterior approach) methyl prednisolone 40mg 1ml and lidocaine
2ml 1%
Group 2(16 patients): Subacromial bursa methylpredisolone and lidocaine
Group 3(8 patients): intra-articular lidocaine 3ml 1%
Group 4(8 patients): intra-bursal lidocaine 3ml 1%
Each patient received 3 injections in same location at intervals of one week and all patients received same
home exercise program and standardized weekly physical therapy treatment for 11 weeks consisting of
ultrasound and therapeutic exercises. All were adivsed to continue NSAIDs

Corticosteroid injections for shoulder pain (Review) 28

Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Rizk 1991 (Continued)

Outcomes Assessed at baseline, weekly for 11 weeks, week 15 and 6 months.

1) Pain on a 6- point rating scale (0=none and 5=extreme)
2) Shoulder passive range of motion expressed as the sum of shoulder motion in 3 planes (internal rotation-
external rotation, flexion- extension, adduction- abduction)

Notes Met inclusion criteria for review but insufficient data presented (ie. no measure of variance or data from
which it could be calculated), therefore not included in meta-analysis.
Concluded no significant difference between groups for pain or range of movement

Risk of bias

Item Authors judgement Description

Allocation concealment? Unclear B - Unclear

Shibata 2001

Methods Randomised controlled trial

Blinding: unclear
Loss to follow-up: none at 4 weeks,
Appropriate statistical analysis: intention to treat only for satisfaction with treatment at 4 weeks

Participants 78 patients
Inclusion criteria:
full thickness rotator cuff tear diagnosed by arthography or MRI.
Exclusion criteria: prior intra-articular injection of any drugs, abnormal hepatic or renal function, preg-
nancy, severe osteoarthritic changes of affected shoulder joint, symptoms resulting from cervical lesions

Interventions Group 1(38 patients): intra-articular injections of 25mg hyaluronate plus 3ml 1% lidocaine
Group 2(40 patients): intra-articular injections of 2mg dexamethasone plus 3ml lidocaine.
Injections were performed once weekly for 5weeks or earlier if shoulder disability resolved during treatment
period.
All patients were prescribed loxoprofen (180mg/day) and physical therapy which included heat and cuff-
strengthening exercise

Outcomes Assessed at baseline and 4 weeks after final injection

1) active abduction, external and internal rotation
2) patients assessment of improvement of symptoms, satisfaction with treatment, desire for surgery for
rotator cuff repair.
3) UCLA score incorporating pain, function, active forward flexion, manual muscle testing and satisfaction
of patients

Notes See analyses 10.

Risk of bias

Item Authors judgement Description

Corticosteroid injections for shoulder pain (Review) 29

Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Shibata 2001 (Continued)

Allocation concealment? Unclear B - Unclear

Strobel 1996

Methods Randomised controlled trial reported in German.

Blinding: unclear
Loss to follow-up: 3(15%) in placebo group and and 6(30%) in steroid injection group did not participate
in follow up
Appropriate statistical analysis: not intention to treat analysis, completers analysis only

Participants 40 patients
Inclusion criteria:
chronic painful shoulder caused by chronic subacromial bursitis or supraspinatus tendinitis - criteria for
diagnoses not reported
Exclusion criteria:
not stated

Interventions Group 1(20 patients): 5ml 0.5% mepivacainhydrochloride (MVH)

injection
Group 2(20 patients): 5ml 0.5% MVH plus 20mg triamcinolone hexacetonid (THA) injection

Outcomes Assessed at baseline, 14, 90 and 360 days

1) Pain (either no pain, low pain, strong pain, very strong pain)
2) angle of abduction reported by patient after eduction in front of a mirror
3) work status

Notes Met inclusion criteria for review but insufficient data presented (ie. no measure of variance or data from
which it could be calculated), therefore not included in meta-analysis.
Reported greater reduction in pain in placebo group at 90 and 360 days but more patients in treated
group were able to work after one year

Risk of bias

Item Authors judgement Description

Allocation concealment? Unclear B - Unclear

Corticosteroid injections for shoulder pain (Review) 30

Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
van der Windt 1998

Methods Randomised controlled trial.

Blinding:
Only outcome assessors were blinded. Patients unable to be blinded since comparing steroid injections to
physiotherapy.
Loss to follow-up: 2 (3.6%) patients withdrew from physiotherapy treatment group and 4 (7.5%) withdrew
from injection group
Appropriate statistical analysis: Yes - intention to treat analysis

Participants 109 patients

Inclusion criteria:
1) painful restriction of glenohumeral mobility - lateral rotation must be relatively more limited than
abduction and medial rotation and must be no clear signs (painful arc, positive resistance tests, loss of
power) that shoulder pain is caused by another condition;
2) 18 yrs or older; 3) informed consent. Exclusion criteria:
1) bilateral shoulder symptoms;
2) treatment with physiotherapy or corticosteroid injections during preceding 6 months;
3) contra
indications to treatment;
4) surgery, dislocation or fracture of shoulder area;
5) insulin dependent diabetes mellitus;
6) systemic disorders of musculoskeletal system or neurological disorders

Interventions Group 1 (53 patients) Intra-articular injections of 40mg triamcinolone acetonide, posterior route, by
mostly trained general practitioners. No more than 3 injections were given during 6 week treatment
period.
Group 2 (56 patients): 12 sessions of physiotherapy over 6 weeks, consisting of 30 minutes of passive
joint mobilisation and exercise treatment. Ice, hot packs, or electrotherapy could also be used to reduce
pain. No ultrasound, acupuncture or high velocity thrust manipulations were allowed under the protocol.
Treatment could be adjusted according to severity of symptoms.
All patients in both groups allowed to could continue taking drugs for pain if they had started before
enrollment; drugs could also be prescribed if pain was severe. All other interventions were to be avoided
during study

Outcomes Assessments made at baseline, 3, 7, 13, 26 and 52 weeks.

1) Patients scored their improvement on a 6-point Likert scale. For analysis of success rates for each
treatment, patients who rated themselves as having made a complete recovery or as having much improved
were counted as successes.
2) Patients were asked to score the pain associated with their main complaint
3) severity of their pain during the day and at night on 100mm visual analogue scale (VAS) where 0 = no
pain and 100 = very severe pain.
4) Functional disability was assessed using shoulder disability questionnaire, a 16-item scale consisting of
common situations which migh cause shoulder pain. Scores on this ranged from 0 (no disability) to 100
(severe disability).
5) Independent observer scored overall clinical severity of the disorder on VAS. Using the healthy shoul-
der as a reference, the observer measured the restriction of mobility during passive lateral rotation and
glenohumeral abduction with a digital inclinometer (EDI-320, Cybex, Ronkonkoma, New York)

Notes See analyses 5.

Corticosteroid injections for shoulder pain (Review) 31

Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
van der Windt 1998 (Continued)

Risk of bias

Item Authors judgement Description

Allocation concealment? Yes A - Adequate

Vecchio 1993

Methods Randomised controlled trial

Blinding: both patients and outcome assessors were blinded
Loss to follow-up: 1 patient from each group failed to complete 12 week assessment period
Appropriate statistical analysis: completers analysis only

Participants 57 patients
Inclusion criteria: clinically defined rotator cuff tendonitis (shoulder pain exacerbated by resistance in at
least one of abduction, external or internal rotation, and normal passive motion).
Duration of symptoms was less than 12 weeks.
Exclusion criteria: Adhesive capsulitis, rotator cuff tears, biceps tendinitis, acromioclavicular arthritis, local
infection and previous steroid injections into shoulders

Interventions Group 1 (28 patients): subacromial injection of 1% lignocaine, 1ml.

Group 2 (29 patients): subacromial injection of 40mg methylprednisolone plus 1ml 1% lignocaine
NSAIDS were discontinued one week prior to study

Outcomes Outcome was assessed at baseline and every 2 weeks for 12 weeks
1) Pain at rest, night and on movement on a 10 cm visual analogue scale
2) Active and passive range of abduction, flexion, internal and external rotation using spirit level goniome-
ter, recorded to nearest 5 degrees

Notes Met inclusion criteria for review but no reported means or standard deviations and no information from
which to calculate them. Reported median change. Therefore included in review but not in meta-analysis
Author contacted but data no longer available.
RESULTS:
Median changes in clinical variables between 0 and 2 weeks, 0 and 4 weeks and 0 and 12 weeks were
presented with interquartile ranges. Reported no statistically significant differences between the treatment
and placebo groups

Risk of bias

Item Authors judgement Description

Allocation concealment? Unclear B - Unclear

Corticosteroid injections for shoulder pain (Review) 32

Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
White 1986

Methods Randomised, controlled trial

Blinding: both participants and outcome assessors were blinded
Loss to follow-up: 5(25%) patients in each group.
Appropriate statistical analysis: yes, intention to treat

Participants 40 patients Inclusion criteria: Rotator cuff tendonitis

Painful arc between 40-120 degrees abduction, shoulder pain less than 12 weeks duration, no signs of
acute calcific tendinitis, no evidence of a systemic inflammatory arthritis or frozen shoulder
(defined as external rotation < 30 degrees, abduction <90 degrees)
Exclusion criteria:
active peptic ulcer disease, recent gastrointestinal bleed, contraindication to NSAIDS, evidence of symp-
tomatic acromioclavicular arthritis or bicipitis tendinitis or major rotator cuff tear

Interventions Group 1 (20 patients): Subacromial injection of 40mg triamcinalone acetonide plus placebo indomethacin
tablets 4x daily
Group 2 (20 patients): 25mg indomethacin 4x daily plus placebo (1cc saline) injection.
Repeat injection and refill of medication was given after 3 weeks, if necessary.
All patients were instructed to begin home exercise program of Codman pendulum exercies. 10-15 min
twice daily and slow shoulder abduction exerceises using finger-up-the-wall technique

Outcomes Assessed at baseline and 3 weeks (final assessment if prompt response) and 6 weeks (for remaining patients)
1) Day and night pain on 9cm VAS scales;
2) overall severity judged by patient on a 0-3 point scale (0=none, 3=severe)
3) Range of abduction measured with a goniometer.
4) Physicians estimate of overall severity of pain and overall severity of motion deficit using 0-3 point
scales where 0=none and 3=severe.
5) global assessment score = sum of patients and physicians estimate of severity of pain and severity of
motion deficit (0 - 9 points)

Notes See analyses 11.

Risk of bias

Item Authors judgement Description

Allocation concealment? Unclear B - Unclear

White 1996

Methods Randomised controlled trial

Blinding: no.
Loss to follow-up: none reported
Appropriate statistical analysis: no statistical analysis comparing efficacy of two interventions

Participants 40 patients Inclusion criteria: Restrictive capsulitis as defined by

1. shoulder pain of spontaneous onset, worse at night
2. Restriction of abduction of less than 100 degrees
3. 50% reduction in external rotation compared to contralateral side

Corticosteroid injections for shoulder pain (Review) 33

Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
White 1996 (Continued)

4. Intact rotator cuff clinically

Exclusion criteria:
cervical spine pathology,
polyarthropathy,
history of significant trauma to the shoulder, history of allergic reaction to any of the injected substances,
any other apparent cause of their shoulder pain

Interventions Group 1 (20 patients): Anterior approach injection of hydrocortisone 25mg, lignocaine 1% 4ml and
urograffin 370, 4ml (radio-opaque marker)
Group 2 (20 patients): Same injection via posterior intra-articular approach

Outcomes Outcome assessed at baseline and 6 weeks

1) pain severity on 10 point scale
2) active abduction
3) external rotation (with elbow at 90 degrees)
Response criteria:
Good: no pain and no analgesia and restoration of abduction to 160 degrees or above:
moderate: reduction in pain and analgesics (if previously taken), and 30 degree increase in abduction;
poor response: persistent nocturnal pain and abduction less than 100 degrees

Notes Met inclusion criteria for review but no results comparing treatment groups.
Reported significantly higher level of injection accuracy with anterior approach - 19/20 (95%) vs 10/20
(50%) with posterior approach (p < 0.02). Reported response for intra-articular (good 5/29, moderate
10/29 and poor 14/29) and extra-articular injections (good 0/11, moderate 3/11 and poor 8/11)

Risk of bias

Item Authors judgement Description

Allocation concealment? Unclear D - Not used

Williams 1975

Methods Randomised controlled trial.

Blinding: no. Loss to follow-up: unclear
Appropriate statistical analysis: unclear

Participants Number of patients in study not reported. Inclusion criteria:

restriction of abduction and external rotation of shoulder for more than one month

Interventions Group 1: 50mg hydrocortisone acetate injection into glenohumeral joint weekly for 3 weeks
Group 2: stellate ganglion block with 10ml of 0.5% Marcaine weekly for 3 weeks.
All patients were shown active shoulder exercises to perform at home and patients were allowed to continue
NSAIDs

Outcomes Assessed at baseline, weekly for 4 weeks and at 3 months

1) active elevation of shoulder
2) passive external rotation

Corticosteroid injections for shoulder pain (Review) 34

Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Williams 1975 (Continued)

3) night pain
4) analgesic consumption
5) patients assessment of their condition from 0-100% whether for better or for worse

Notes Abstract only. No data reported, thus included in review but not in meta-analysis.
Reported that half patients in both group assessed their improvement as 75% or more, a quarter as more
than 25% improved and one fifth as no improvement at all with similar findings reported for range of
movement. There were no reported differences in outcome between treatment groups at 4 weeks and 3
months

Risk of bias

Item Authors judgement Description

Allocation concealment? Unclear D - Not used

Winters 1997

Methods Randomised controlled trial

Blinding: patients unable to be blinded but outcome assessors were blinded
Loss to follow-up: Synovial group: 19(59%) of manipulation group, 18(51%) of physio group, 7(15%)
of steroid injection group
Appropriate statistical analysis: yes, intention to treat.

Participants 114 patients. Inclusion criteria:

Shoulder complaints defined as pain localised in region of deltoid muscle, acromioclavicular joint, superior
part of trapezoid muscle and scapula). Radiation of pain in the arm could be present, and, besides the
pain, the range of movement of the upper arm or shoulder girdle could be limited. Exclusion criteria
included: treatment for shoulder
complaint in prior 6 months, bilateral shoulder complaints, presence of specific rheumatic disorders
(polymyalgia rheumatica, rheumatoid arthritis systemic lupus erythematosus & fibromyalgia), acute severe
trauma such as fracture, dislocation, cuff rupture, and herniated cervical disc.
There were 3 diagnostic groups (synovial, shoulder girdle and combination). Only the synoivial group is
considered in this review.
The synovial group consisted of 114 patients with pain or limited movement in one or several directions
of the glenohumeral joint. These complaints origniated from disorders of the subacromial structures, the
acromioclavicular joint, the glenohumeral joint, or combinations of these (the synovial structures)

Interventions First week: All received 50 mg diclofenac sodium three times daily.
Then on the basis of reassessment they were divided into diagnostic groups.
Within the synovial group, patients were allocated to
group A (47 patients): corticosteroid injection (1-3 injections as needed at baseline, 1 week and after 2
weeks, of 1 ml of 40 mg/ml triamcinolone acetonide with 9 ml of 10 mg/ml lignocaine) into 2 out of 3
synovial structires (glenohumeral joint capsule, subacromial space, and acromioclavicular joint;
Group B (32 patients): manipulation and mobilisation of cervical spine, upper thoracic spine, upper ribs,
acromioclavicular joint, glenohumeral joint once weekly with a maximum of 6 treatments); Group C (35
patients): physiotherapy twice a week. Could use exercise therapy, massage, physical applications but no
mobilisation or manipulative techniques were allowed

Corticosteroid injections for shoulder pain (Review) 35

Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Winters 1997 (Continued)

Outcomes Assessment at baseline and 2, 6, 11 weeks.

1) Pain assessed by the shoulder pain score (6 item questionnaire and and 101 point numerical pain scale)
(7 points = no pain to 28 =severe pain)
2) active and passive range of movement of glenohumeral joint, cervical spine, upper thoracic spine,
palpating the muscle tendons on the head of humerus, the AC joint, and the upper ribs
3) felt cured (defined as disappearance of shoulder complaints or a decrease to such an extent that they
were no longer inconvenient, did not need treatment, or no longer interfered with normal working) or if
treatment failed

Notes See analyses 12, 13.

Risk of bias

Item Authors judgement Description

Allocation concealment? Unclear B - Unclear

Withrington 1985

Methods Randomised controlled trial

Blinding: both patients and outcome assessor were blinded.
Loss to follow-up: none
Appropriate statistical analysis: yes, intention to treat.

Participants 25 patients Inclusion criteria: Supraspinatus tendonitis defined as a clinical entity of tenderness over the
supraspinatus tendon, pain on resisted abduction and normal passive gleno humeral range.
Exclusion criteria: past history or clinical evidence of inflammatory arthritis

Interventions Group 1(12 patients): affected supraspinatus tendon injected with 80mg methylprednisolone diluted in
2 ml 2% lignocaine (a total of 4 ml)
Group 2(13 paitents): Placebo injection 4ml 0.9% normal saline at the same site.
All patients encouraged to move shoulders through full range of movement in subsequent days but no
formal physiotherapy

Outcomes Assessed at baseline, 2 and 8 weeks

1) Pain on 10cm VAS
2) Paracetomol count

Notes Met inclusion crieria of review but insufficient data presented (ie. no measure of variance or data from
which it could be calculated), therefore not included in meta-analysis.
Reported no difference in improvement in pain or analgesic consumption between the two groups at 2
and 8 weeks of follow-up

Risk of bias

Item Authors judgement Description

Corticosteroid injections for shoulder pain (Review) 36

Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Withrington 1985 (Continued)

Allocation concealment? Unclear B - Unclear

Characteristics of excluded studies [ordered by study ID]

Study Reason for exclusion

Blyth 1993 Excluded on basis of population (rheumatoid arthritis was an exclusion criterion for review)

Corbeil 1992 Randomised controlled trial of distension and non-distension arthrography in combination witth intra-artic-
ular injection of corticosteroid. Included in hydrodilatation review

Gado 1996 Population included 6 patients (33% of total population) with rheumatoid arthriritis (excluded from review)

Hardy 1986 Is a randomised trial of indomethacin (NSAID) with cortico-steroid injection, but no treatment outcome
reported. Aim of study was to assess use of X-Ray as a prognostic indicator of outcome

Lloyd-Roberts 1959 Trial not randomised.

Mardjuadi 1978 Trial not randomised.

Murnaghan 1955 Trial not randomised. Patients allocated to study groups by day of presentation

Quin 1965 Trial not randomised. Patients allocated to treatment groups alternately

Rovetta 1998 Randomised controlled trial comparing intra-articular steroid injection and sodium hyaluronate versus intra-
articular steroid injection alone. No information about the benefit of intra-articular steroid injection

Shanahan 200x Randomised controlled trial but study population included xx patients (%) with rheumatoid arthritis. Data
not presented separately

Thomas 1980 Randomised controlled trial comparing manipulation under anaesthesia and intra-articular steroid injection
versus intra-articular steroid injection alone for adhesive capsulitis. No information about benefit of intra-
articular steroid injection. Included in the surgery review

Valtonen 1974 Trial not randomised. Patients paired off then given placebo or intervention in series

Valtonen 1978 Trial not randomised. Patients allocated to treatment group according to birth date

Weiss 1978 Not a randomised controlled trial.

Corticosteroid injections for shoulder pain (Review) 37

Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
DATA AND ANALYSES

Comparison 1. INTRA-ARTICULAR STEROID INJECTION VS PLACEBO

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Pain at 4 weeks 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
1.1 Rotator cuff disease 1 24 Mean Difference (IV, Fixed, 95% CI) 4.60 [-15.99, 25.19]
2 Range of abduction at 4 weeks 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
2.1 Rotator cuff disease 1 24 Mean Difference (IV, Fixed, 95% CI) -20.20 [-47.50, 7.
10]
3 Success rate at 4 weeks 1 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
3.1 Rotator cuff disease 1 24 Risk Ratio (M-H, Fixed, 95% CI) 0.67 [0.35, 1.28]

Comparison 2. SUBACROMIAL STEROID INJECTION VS PLACEBO

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Improvement in pain at 4 weeks 2 90 Std. Mean Difference (IV, Fixed, 95% CI) 0.83 [0.39, 1.26]
1.1 Rotator cuff disease 2 90 Std. Mean Difference (IV, Fixed, 95% CI) 0.83 [0.39, 1.26]
2 Improvement in function at 4 2 90 Std. Mean Difference (IV, Fixed, 95% CI) 0.63 [0.20, 1.06]
weeks
2.1 Rotator cuff disease 2 90 Std. Mean Difference (IV, Fixed, 95% CI) 0.63 [0.20, 1.06]
3 Improvement in range of active 2 90 Std. Mean Difference (IV, Fixed, 95% CI) 0.82 [0.39, 1.25]
abduction at 4 weeks
3.1 Rotator cuff disease 2 90 Std. Mean Difference (IV, Fixed, 95% CI) 0.82 [0.39, 1.25]
4 Remission at 4 weeks 1 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
4.1 Rotator cuff disease 1 50 Risk Ratio (M-H, Fixed, 95% CI) 3.5 [0.80, 15.23]

Comparison 3. ANATOMICAL STEROID INJECTION (SITE DETERMINED BY CLINICAL FEATURES) VS

TRIGGER POINT STEROID INJECTION

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Success rate at 1 week 1 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
1.1 General shoulder pain 1 92 Risk Ratio (M-H, Fixed, 95% CI) 2.96 [1.62, 5.42]
(including tendinitis, bursitis,
capsulitis and acromioclavicular
joint strain
1.2 All diagnoses excluding 1 68 Risk Ratio (M-H, Fixed, 95% CI) 2.55 [1.45, 4.47]
capsulitis

Corticosteroid injections for shoulder pain (Review) 38

Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Comparison 4. INTRA-ARTICULAR STEROID INJECTION - HIGHER DOSE (40 mg TRIAMCINOLONE
ACTONIDE) VS LOWER DOSE (10 MG)

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Improvement in pain at 6 weeks 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
1.1 Adhesive capsulitis 1 57 Mean Difference (IV, Fixed, 95% CI) -18.10 [-37.11, 0.
91]
2 Improvement in disturbance of 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
sleep at 6 weeks
2.1 Adhesive capsulitis 1 57 Mean Difference (IV, Fixed, 95% CI) Not estimable
3 Improvement in functional 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
impairment at 6 weeks
3.1 adhesive capsulitis 1 57 Mean Difference (IV, Fixed, 95% CI) -0.60 [-1.05, -0.15]
4 Improvement in external 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
rotation at 6 weeks
4.1 Adhesive capsulitis 1 57 Mean Difference (IV, Fixed, 95% CI) -0.40 [-0.79, -0.01]
5 Frequency of adverse effects 1 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
5.1 Pain 1 57 Risk Ratio (M-H, Fixed, 95% CI) 0.98 [0.29, 3.26]
5.2 Flush reaction 1 57 Risk Ratio (M-H, Fixed, 95% CI) 0.47 [0.12, 1.78]
5.3 Menstrual irregularities 1 57 Risk Ratio (M-H, Fixed, 95% CI) 5.52 [0.30, 102.08]
5.4 Headache 1 57 Risk Ratio (M-H, Fixed, 95% CI) 7.09 [0.40, 125.84]
5.5 Rash 1 57 Risk Ratio (M-H, Fixed, 95% CI) 0.26 [0.01, 6.18]

Comparison 5. INTRA-ARTICULAR STEROID INJECTION VS PHYSIOTHERAPY

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Treatment success at 7 weeks 1 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
1.1 Adhesive capsulitis 1 108 Risk Ratio (M-H, Fixed, 95% CI) 1.66 [1.21, 2.28]
2 Improvement in severity of main 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
complaint at 3 weeks
2.1 Adhesive capsulitis 1 107 Mean Difference (IV, Fixed, 95% CI) 15.0 [6.01, 23.99]
3 Improvement in pain during day 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
at 3 weeks
3.1 Adhesive capsulitis 1 107 Mean Difference (IV, Fixed, 95% CI) 12.0 [5.27, 18.73]
4 Improvement in pain at night at 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
3 weeks
4.1 Adhesive capsulitis 1 107 Mean Difference (IV, Fixed, 95% CI) 12.0 [2.68, 21.32]
5 Improvement in pain as rated by 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
an observer at 3 weeks
5.1 Adhesive capsulitis 1 107 Mean Difference (IV, Fixed, 95% CI) 13.00 [6.37, 19.63]
6 Improvement in functional 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
disability at 3 weeks
6.1 Adhesive capsulitis 1 107 Mean Difference (IV, Fixed, 95% CI) 13.0 [3.64, 22.36]
Corticosteroid injections for shoulder pain (Review) 39
Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
7 improvement in abduction at 3 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
weeks
7.1 Adhesive capsulitis 1 107 Mean Difference (IV, Fixed, 95% CI) 5.0 [0.26, 9.74]
8 Improvement in severity of main 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
complaint at 7 weeks
8.1 Adhesive capsulitis 1 108 Mean Difference (IV, Fixed, 95% CI) 26.0 [15.25, 36.75]
9 Improvement in pain during day 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
at 7 weeks
9.1 Adhesive capsulitis 1 108 Mean Difference (IV, Fixed, 95% CI) 26.0 [15.25, 36.75]
10 Improvement in pain at night 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
at 7 weeks
10.1 Adhesive capsulitis 1 108 Mean Difference (IV, Fixed, 95% CI) 12.0 [3.69, 20.31]
11 Improvement in pain as rated 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
by observer at 7 weeks
11.1 Adhesive capsulitis 1 108 Mean Difference (IV, Fixed, 95% CI) 15.0 [7.45, 22.55]
12 Improvement in functional 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
disability at 7 weeks
12.1 Adhesive capsulitis 1 108 Mean Difference (IV, Fixed, 95% CI) 25.0 [14.81, 35.19]
13 Improvement in abduction at 7 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
weeks
13.1 Adhesive capsulitis 1 108 Mean Difference (IV, Fixed, 95% CI) 5.0 [0.27, 9.73]
14 improvement in severity of 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
main complaint at 13 weeks
14.1 Adhesive capsulitis 1 107 Mean Difference (IV, Fixed, 95% CI) 19.0 [7.43, 30.57]
15 Improvement in pain during 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
day at 13 weeks
15.1 Adhesive capsulitis 1 107 Mean Difference (IV, Fixed, 95% CI) 9.0 [-1.82, 19.82]
16 Improvement in pain at night 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
at 13 weeks
16.1 Adhesive capsulitis 1 107 Mean Difference (IV, Fixed, 95% CI) 9.0 [-1.82, 19.82]
17 Improvement in shoulder 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
disability at 13 weeks
17.1 Adhesove capsulitis 1 107 Mean Difference (IV, Fixed, 95% CI) 10.00 [-1.94, 21.94]
18 Improvement in severity of 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
main complaint at 26 weeks
18.1 Adhesive capsulitis 1 105 Mean Difference (IV, Fixed, 95% CI) 9.0 [-1.52, 19.52]
19 Improvement in pain during 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
day at 26 weeks
19.1 Adhesive capsulitis 1 105 Mean Difference (IV, Fixed, 95% CI) Not estimable
20 Improvement in pain during 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
night at 26 weeks
20.1 Adhesive capsulitis 1 105 Mean Difference (IV, Fixed, 95% CI) 1.0 [-13.74, 15.74]
21 Improvement in pain as rated 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
by observer at 26 weeks
21.1 Adhesive capsulitis 1 105 Mean Difference (IV, Fixed, 95% CI) 2.0 [-7.76, 11.76]
22 Improvement in functional 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
disability at 26 weeks
22.1 Adhesive capsulitis 1 105 Mean Difference (IV, Fixed, 95% CI) 12.0 [-0.25, 24.25]
23 Improvement in abduction at 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
26 weeks
23.1 Adhesive capsulitis 1 105 Mean Difference (IV, Fixed, 95% CI) 2.0 [-3.60, 7.60]

Corticosteroid injections for shoulder pain (Review) 40

Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
24 Improvement in severity of 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
main complaint at 52 weeks
24.1 Adhesive capsulitis 1 103 Mean Difference (IV, Fixed, 95% CI) 11.0 [0.55, 21.45]
25 Improvement in pain during 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
day at 52 weeks
25.1 Adhesive capsulitis 1 103 Mean Difference (IV, Fixed, 95% CI) 3.0 [-6.46, 12.46]
26 Improvement in pain at night 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
at 52 weeks
26.1 Adhesive capsulitis 1 103 Mean Difference (IV, Fixed, 95% CI) 2.0 [-11.91, 15.91]
27 Improvement in shoulder 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
disabiltiy at 52 weeks
27.1 Adhesive capsulitis 1 103 Mean Difference (IV, Fixed, 95% CI) 4.0 [-8.95, 16.95]
28 Frequency of adverse effects 1 Risk Ratio (M-H, Fixed, 95% CI) Totals not selected
28.1 Pain after treatment 1 Risk Ratio (M-H, Fixed, 95% CI) Not estimable
lasting more than 2 days
28.2 Facial flushing 1 Risk Ratio (M-H, Fixed, 95% CI) Not estimable
28.3 Irregular mestrual 1 Risk Ratio (M-H, Fixed, 95% CI) Not estimable
bleeding
28.4 Fever reported by patient 1 Risk Ratio (M-H, Fixed, 95% CI) Not estimable
28.5 Skin irritation 1 Risk Ratio (M-H, Fixed, 95% CI) Not estimable
28.6 Overall frequency of 1 Risk Ratio (M-H, Fixed, 95% CI) Not estimable
adverse reactions

Comparison 6. INTRA-ARTICULAR STEROID INJECTION VS PHYSIOTHERAPY AND NSAID

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Pain at 2 weeks 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
1.1 Adhesive capsulitis 1 20 Mean Difference (IV, Fixed, 95% CI) 0.40 [-0.61, 1.41]
2 Pain at 12 weeks 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
2.1 Adhesive capsulitis 1 20 Mean Difference (IV, Fixed, 95% CI) -0.40 [-1.10, 0.30]

Comparison 7. INTRA-ARTICULAR STEROID INJECTION VS CAPSULAR DISTENSION WITH AIR

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Improvement in abduction at 16 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
weeks
1.1 Adhesive capsulitis 1 29 Mean Difference (IV, Fixed, 95% CI) 2.4 [-1.68, 6.48]

Corticosteroid injections for shoulder pain (Review) 41

Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Comparison 8. INTRA-ARTICULAR STEROID INJECTIONS VS ULTRASOUND

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Pain at 4 weeks 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
1.1 Rotator cuff disease 1 24 Mean Difference (IV, Fixed, 95% CI) -14.60 [-38.91, 9.
71]
2 Range of abduction at 4 weeks 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
2.1 Rotator cuff disease 1 24 Mean Difference (IV, Fixed, 95% CI) 5.0 [-24.93, 34.93]
3 Success rate at 4 weeks 1 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
3.1 Rotator cuff disease 1 24 Risk Ratio (M-H, Fixed, 95% CI) 1.0 [0.45, 2.23]

Comparison 9. INTRA-ARTICULAR STEROID INJECTION VS ACUPUNCTURE

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Pain at 4 weeks 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
1.1 Rotator cuff disease 1 24 Mean Difference (IV, Fixed, 95% CI) -7.5 [-27.47, 12.47]
2 Range of abduction at 4 weeks 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
2.1 Rotator cuff disease 1 24 Mean Difference (IV, Fixed, 95% CI) -2.90 [-32.63, 26.
83]
3 Success rate at 4 weeks 1 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
3.1 Rotator cuff disease 1 24 Risk Ratio (M-H, Fixed, 95% CI) 0.83 [0.35, 2.00]

Comparison 10. INTRA-ARTICULAR STEROID INJECTION VS HYALURONATE INJECTION

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Satisfaction with treatment at 4 1 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
weeks
1.1 Full thickness rotator cuff 1 78 Risk Ratio (M-H, Fixed, 95% CI) 0.89 [0.52, 1.54]
tear

Corticosteroid injections for shoulder pain (Review) 42

Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Comparison 11. SUBACROMIAL STEROID INJECTION VS NSAID

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Improvement in pain at 4 or 6 3 120 Std. Mean Difference (IV, Fixed, 95% CI) -0.18 [-0.54, 0.18]
weeks
1.1 Rotator cuff disease 3 120 Std. Mean Difference (IV, Fixed, 95% CI) -0.18 [-0.54, 0.18]
2 Improvement in function at 4 or 2 90 Std. Mean Difference (IV, Fixed, 95% CI) 0.03 [-0.39, 0.44]
6 weeks
2.1 Rotator cuff disease 2 90 Std. Mean Difference (IV, Fixed, 95% CI) 0.03 [-0.39, 0.44]
3 Improvement in range of 3 120 Std. Mean Difference (IV, Fixed, 95% CI) -0.17 [-0.53, 0.19]
shoulder abduction at 4 or 6
weeks
3.1 Rotator cuff disease 3 120 Std. Mean Difference (IV, Fixed, 95% CI) -0.17 [-0.53, 0.19]
4 Improvement in global 1 Std. Mean Difference (IV, Fixed, 95% CI) Subtotals only
assessment score at 6 weeks
4.1 Rotator cuff disease 1 30 Std. Mean Difference (IV, Fixed, 95% CI) -0.03 [-0.75, 0.68]

Comparison 12. INTRA-ARTICULAR, SUBACROMIAL AND ACROMIOCLAVICULAR STEROID INJEC-

TIONS VS PHYSIOTHERAPY (NOT MANIPULATION)

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Pain at end of treatment (when 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
patient left study or 11 weeks
after randomisation)
1.1 General shoulder pain 1 82 Mean Difference (IV, Fixed, 95% CI) -2.30 [-4.10, -0.50]
(mixed diagnoses)

Comparison 13. INTRA-ARTICULAR, SUBACROMIAL and ACROMIOCLAVICULAR STEROID INJEC-

TIONS VS MANIPULATION

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Pain at end of treatment (when 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
patient left study or 11 weeks
after randomisation)
1.1 General shoulder pain 1 79 Mean Difference (IV, Fixed, 95% CI) -3.40 [-5.46, -1.34]
(mixed diagnoses)

Corticosteroid injections for shoulder pain (Review) 43

Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Comparison 14. INTRA-ARTICULAR STEROID INJECTION PLUS NSAID VS PLACEBO

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Pain at 4 weeks 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
1.1 Rotator cuff disease 1 24 Mean Difference (IV, Fixed, 95% CI) 7.20 [-14.03, 28.43]
2 Range of abduction at 4 weeks 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
2.1 Rotator cuff disease 1 24 Mean Difference (IV, Fixed, 95% CI) -27.60 [-49.99, -5.
21]
3 Success rate at 4 weeks 1 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
3.1 Rotator cuff disease 1 24 Risk Ratio (M-H, Fixed, 95% CI) 0.56 [0.26, 1.17]

Comparison 15. INTRA-ARTICULAR STEROID INJECTION PLUS MANIPULATION UNDER ANAESTHE-

SIA VS MANIPULATION UNDER ANAESTHESIA ALONE

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Range of abduction at 4 months 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
1.1 Adhesive capsulitis 1 24 Mean Difference (IV, Fixed, 95% CI) -3.0 [-16.20, 10.20]

Comparison 16. SUBACROMIAL STEROID INJECTION PLUS NSAID VS NSAID ALONE

No. of No. of
Outcome or subgroup title studies participants Statistical method Effect size

1 Improvement in pain at 4 weeks 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
1.1 Rotator cuff disease 1 50 Mean Difference (IV, Fixed, 95% CI) 0.19 [-0.73, 1.11]
2 Improvement in function at 4 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
weeks
2.1 Rotator cuff disease 1 50 Mean Difference (IV, Fixed, 95% CI) -0.10 [-0.96, 0.76]
3 Improvement in range of 1 Mean Difference (IV, Fixed, 95% CI) Subtotals only
abduction at 4 weeks
3.1 Rotator cuff disease 1 50 Mean Difference (IV, Fixed, 95% CI) 0.56 [-0.15, 1.27]
4 Remission at 4 weeks 1 Risk Ratio (M-H, Fixed, 95% CI) Subtotals only
4.1 Rotator cuff disease 1 50 Risk Ratio (M-H, Fixed, 95% CI) 1.0 [0.41, 2.43]

Corticosteroid injections for shoulder pain (Review) 44

Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
WHATS NEW
Last assessed as up-to-date: 18 November 2002.

Date Event Description

22 September 2008 Amended Converted to new review format. C020-R

HISTORY
Review first published: Issue 1, 2003

CONTRIBUTIONS OF AUTHORS
All reviewers contributed to the development of this review.

DECLARATIONS OF INTEREST
None known.

SOURCES OF SUPPORT

Internal sources
Department of Clinical Epidemiology, Cabrini Hospital, Melbourne, Australia.
Monash University Department of Epidemiology and Preventive Medicine, Melbourne, Australia.

External sources
No sources of support supplied

INDEX TERMS

Medical Subject Headings (MeSH)

Adrenal Cortex Hormones [ therapeutic use]; Anti-Inflammatory Agents, Non-Steroidal [therapeutic use]; Bursitis [ drug therapy];
Injections, Intra-Articular; Randomized Controlled Trials as Topic; Rotator Cuff [ injuries]; Shoulder Pain [ drug therapy]

Corticosteroid injections for shoulder pain (Review) 45

Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
MeSH check words
Adult; Humans

Corticosteroid injections for shoulder pain (Review) 46

Copyright 2009 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.