Ultrasound-guided versus blind subacromial—subdeltoid bursa injection in adults with shoulder pain: A systematic review and meta-analysis

doi:10.1016/j.semarthrit.2015.05.011

Seminars in Arthritis and Rheumatism

Volume 45, Issue 3, December 2015, Pages 374-378

https://doi.org/10.1016/j.semarthrit.2015.05.011 Get rights and content

Abstract

Objective

This systematic review and meta-analysis aimed to assess the effectiveness of ultrasound-guided (USG) versus blind (landmark-guided, LMG) corticosteroid subacromial–subdeltoid bursa injection in adults with shoulder pain.

Methods

The searches were performed on PubMed, Ovid MEDLINE, Ovid EMBASE, Ovid CochraneCENTRAL, Web of Science, Google Scholar, and Scopus from database inception through March 27, 2015. Studies were included trials comparing USG versus LSG injections for the treatment of adults with subacromial–subdeltoid bursitis. Two reviewers independently performed data extraction and appraisal of the studies. The outcome measures collected were the decreased VAS and SDQ scores, the increased shoulder function scores and shoulder abduction motion range, and the effective rate at 6 weeks after injection.

Results

Seven papers including 445 patients were reviewed; 224 received LMG injections and 221 received USG injections. There was a statistically significant difference in favor of USG for pain score [MD = 1.19, 95% CI (0.39, 1.98), P = 0.003] and SDQ score [MD = 5.01, 95% CI (1.82, 8.19), P = 0.02] at 6 weeks after injection. Also there was a statistically significant difference between the groups, with greater improvement reported of shoulder function scores [SMD = 0.89, 95% CI (0.56, 1.23), P < 0.001] and shoulder abduction motion range [MD 32.69, 95% CI (14.82, 50.56), P < 0.001] in the USG group. More effective rate was also reported with USG group and the difference was statistically significant [risk ratio = 1.6, 95% CI (1.02, 2.50), P = 0.04].

Conclusions

Ultrasound-guided corticosteroid injections potentially offer a significantly greater clinical improvement over blind SASD bursitis injections in adults with shoulder pain.

Section snippets

Methods

This systematic review of randomized controlled trials was performed according to the current recommendations of the Cochrane Collaboration [11] and reported using the criteria of the PRISMA statement [12].

Statistical analysis

All analyses were performed using the generic inverse variance method (Rev Man 5.3, The Cochrane Library). Statistical heterogeneity was quantified using the I² statistic and the chi-square-based test. The decreased VAS and SDQ scores, increased shoulder function scores, and shoulder abduction motion range at 6 weeks after injection between USG and LMG groups were expressed in terms of the weighted mean difference or standard mean difference with a 95% confidence interval (CI) evaluation. For

Results

We identified 305 articles; seven RCTs were eligible for this review (Fig. 1), with a total of 445 adult patients [13], [14], [15], [16], [17], [18], [19]. Characteristics of the enrolled studies are described in Table 1.

Discussion

The purpose of this study was to assess whether there is a difference in the clinical and functional outcomes of USG versus LMG SASD bursa injections in adults with shoulder pain based on the current evidence base. A total of eight RCTs were included in our meta-analysis. The results showed that USG SASD injections were more efficient than the LMG injections. USG injections significantly decreased the VAS and SDQ scores, and increased shoulder function and shoulder abduction motion range at 6

Conclusions

The meta-analysis in this study provides evidence that ultrasound-guided corticosteroid injections potentially offer a significantly greater clinical improvement over blind SASD injections in adults with shoulder pain. Therefore, we believe that the US-guided SASD injection technique can be a useful treatment that leads to improvements in patients with SASD bursitis.

Acknowledgments

We would like to thank all authors who shared individual patient data. No funding was received for this study.

References (24)

O. Lorbach et al.
Nonoperative management of adhesive capsulitis of the shoulder: oral cortisone application versus intra-articular cortisone injections
J Shoulder Elbow Surg
(2010)
H.J. Lee et al.
Randomized controlled trial for efficacy of intra-articular injection for adhesive capsulitis: ultrasonography-guided versus blind technique
Arch Phys Med Rehabil
(2009)
P. Zufferey et al.
A controlled trial of the benefits of ultrasound-guided steroid injection for shoulder pain
Joint Bone Spine
(2012)
C.R. Rowe
Injection technique for the shoulder and elbow
Orthop Clin North Am
(1988)
J.A. Strakowski et al.
Upper limb musculoskeletal pain syndromes
R. Steinfeld et al.
Massive subacromial bursitis with rice bodies
Clin Orthop
(1994)
R. Buchbinder et al.
Corticosteroid injections for shoulder pain
Cochrane Database Syst Rev
(2003)
B. Blair et al.
Efficacy of injections of corticosteroids for subacromial impingement syndrome
J Bone Joint Surg Am
(1996)
M.M. Hall
The accuracy and efficacy of palpation versus image-guided peripheral injections in sports medicine
Curr Sports Med Rep
(2013)
A.R. Aly et al.
Ultrasound-guided shoulder girdle injections are more accurate and more effective than landmark-guided injections: a systematic review and meta-analysis
Br J Sports Med
(2014)

E. Soh et al.

Image-guided versus blind corticosteroid injections in adults with shoulder pain: a systematic review

BMC Musculoskelet Disord

(2011)

K.T. Amber et al.

Comparing the accuracy of ultrasound versus fluoroscopy in glenohumeral injections: a systematic review and meta-analysis

J Clin Ultrasound

(2014)

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To compare the efficacy of rotator interval (RI) vs posterior approach (PA) ultrasound (US) guided corticosteroid injections into the glenohumeral (GH) joint in primary frozen shoulder (PFS).
A systematic literature search for all relevant studies on Medline, Scopus, Embase, Web of Science, and Cochrane Central, up to January 2023 was conducted.
Randomized controlled trials that directly compared the US-guided corticosteroid injection into the RI and GH joint using PA in patients clinically and radiographically diagnosed with PFS.
The primary outcome was pain, and the secondary outcomes were function, and range of motion (ROM). Two authors independently assessed the risk of bias using the Cochrane risk-of-bias tool version 2. A random-effects model and generic inverse variance method were performed. Effect sizes were estimated using mean difference (MD) and standardized mean difference (SMD).
A total of 5 clinical trials involving 323 subjects were included for the meta-analysis. US-guided corticosteroid injections into the RI revealed significant pain relief (MD 1.33 [95% confidence interval (CI) 0.20 to 2.46]; P=.02) and significant functional improvement (SMD 1.31 [95% CI 0.11 to 2.51]; P=.03) compared with the PA after 12 weeks.
The results suggest the injection of corticosteroid into RI space is more effective than PA after 12 weeks in improving both pain and functional scores in patients with PFS.
Current evidence and practical knowledge for ultrasound-guided procedures in rheumatology: Joint aspiration, injection, and other applications
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Ultrasound (US)-guided procedures have increasingly gained their role in the daily practice of rheumatology, owing to the growing evidence supporting their utility. The utilization of US guidance in procedures may enhance their accuracy, efficacy, and safety. This article presents a comprehensive review of the current evidence and practical knowledge pertaining to US-guided procedures in rheumatology, encompassing joint aspirations, injections, and other applications such as tendon sheath injections. We provide a detailed description of the US-guided procedure process and compare the in-plane and out-of-plane view methods, along with practical techniques based on existing evidence or our own expertise. For each joint, we summarize how to perform procedures with figures to facilitate a better understanding. Additionally, we introduce other applications of US-guided procedures for tendons, enthesis, bursae, and nerves as well as emerging therapies such as US-guided fascia hydrorelease. By utilizing these US techniques, rheumatologists can achieve the ability to manage a wider range of musculoskeletal conditions.
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Citation Excerpt :
The ideal shoulder injection can provide patients with both relief and clarity about the cause of the pain. In the present study, the preliminary analysis suggested no statistically significant difference (MD 0.41 [−0.02, 0.44]; I2 = 74%; P = .06) in the VAS score, a finding supported by that in Ayekoloye et al.37 Four studies showed that the USG group had a significantly greater pain relief because of the limited number of literature included in previous studies.12,38-40 To further explore the heterogeneity, 2 subgroup analyses were performed in the present study.
To perform a meta-analysis comparing the clinical and functional outcomes of ultrasound-guided (USG) and blind injections for shoulder pain.
The Embase, Cochrane Library, and PubMed databases were searched from database inception to April 7, 2021. Clinical and functional outcomes included the visual analog scale (VAS) pain score, abduction, flexion, American Shoulder and Elbow Surgeons Assessment Form (ASES) score, Constant-Murley Shoulder (CMS) score, Shoulder Pain and Disability Index (SPADI), Shoulder Disability Questionnaire (SDQ) score, and Shorted Disabilities of the Arm, Shoulder and Hand (Quick DASH) score. Dichotomous outcomes were assessed with mean differences (MDs) and 95% confidence intervals (95% CIs).
Fifteen studies that compared USG and blind injections were included. No significant difference was found in the VAS score between the blind group and USG group (MD 0.41 [−0.02, 0.84]; I² = 79%; P = .06). Subgroup analysis of the brachial bicipital groove indicated that the USG group had less pain than the blind group (MD 1.50 [0.54, 2.46]; I² = 64; P = .002). The USG injection patients had better postoperative abduction (MD −3.08 [−5.19, −0.98], I² = 0, P = .004) and flexion (MD −3.36 [−5.56, −1.16]; I² = 0; P = .003) than the blind group. Additionally, the USG injection patients had better CMS scores than the blind injection patients (MD −12.95 [−25.60, −0.29]; I² = 96; P = .04). However, subgroup analysis showed no significant difference in the subacromial bursas and glenohumeral joints of CMS score (MD −13.22 [−29.93, 3.94]; I² = 97; P＜.0001). No significant difference was found in the SPADI, ASES score, or SDQ score between the groups.
Ultrasound guidance is not superior in the subacromial bursa and glenohumeral joint injections in pain or function. However, injection in the brachial bicipital groove, is still superior to blind injection of pain relief.
Level II, meta-analysis of Level I and II studies.
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The study aimed to investigate whether the shoulder tendons changed their elasticity after ultrasound-guided peritendinous or intrabursal corticosteroid injections.
Post hoc secondary analysis of a double-blinded, randomized controlled study with 3 months of follow-up.
Outpatient rehabilitation clinic.
Patients with subacromial impingement syndrome (N=60).
Patients with unilateral shoulder pain were randomly assigned to receive standard ultrasound-guided subacromial or dual-target corticosteroid injections. The supraspinatus tendons were exposed to 40 mg triamcinolone acetonide in the formal group, whereas the long head of the biceps brachii tendons (LHBT) and supraspinatus tendons were individually infiltrated by 20 mg triamcinolone acetonide in the latter group. Patients’ bilateral shoulders were divided into group 1 (n=30, receiving standard subacromial injections), group 2 (n=30, receiving dual-target injections), and group 3 (n=60, without injections).
Strain ratio of LHBT and supraspinatus tendons using ultrasound elastography.
The repeated-measures analysis of variance revealed no intragroup difference of the strain ratio of the LHBT (P=.412 for group 1, P=.936 for group 2, P=.131 for group 3) and supraspinatus tendon (P=.309 for group 1, P=.067 for group 2, P=.860 for group 3) across the 3 time points. Treating group 3 as the reference, the linear mixed model revealed no significant changes in tendon elasticity after either the standard subacromial injection (P=.205 for the LHBT and P=.529 for the supraspinatus tendon) or the dual-target injection (P=.961 for the LHBT and P=.831 for the supraspinatus tendon).
Elasticity of the LHBT and supraspinatus tendons is unlikely to change after a single dose of peritendinous or intrabursal corticosteroid injections. Future studies with a shorter follow-up interval are needed to validate whether corticosteroid injections can cause transient changes of the tendon’s elasticity.
The Shoulder and Elbow: Pain Medicine: A Case-Based Learning Series
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View all citing articles on Scopus

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Ultrasound-guided versus blind subacromial—subdeltoid bursa injection in adults with shoulder pain: A systematic review and meta-analysis

Abstract

Objective

Methods

Results

Conclusions

Section snippets

Methods

Statistical analysis

Results

Discussion

Conclusions

Acknowledgments

J Shoulder Elbow Surg

Arch Phys Med Rehabil

Joint Bone Spine

Orthop Clin North Am

Upper limb musculoskeletal pain syndromes

Massive subacromial bursitis with rice bodies

Clin Orthop

Corticosteroid injections for shoulder pain

Cochrane Database Syst Rev

Efficacy of injections of corticosteroids for subacromial impingement syndrome

J Bone Joint Surg Am

The accuracy and efficacy of palpation versus image-guided peripheral injections in sports medicine

Curr Sports Med Rep

Ultrasound-guided shoulder girdle injections are more accurate and more effective than landmark-guided injections: a systematic review and meta-analysis

Br J Sports Med

Image-guided versus blind corticosteroid injections in adults with shoulder pain: a systematic review

BMC Musculoskelet Disord

Comparing the accuracy of ultrasound versus fluoroscopy in glenohumeral injections: a systematic review and meta-analysis

J Clin Ultrasound