Positive outcomes with intra-articular glenohumeral injections are independent of accuracy

Hegedus, Eric J.; Zavala, John; Kissenberth, Michael; Cook, Chad; Cassas, Kyle; Hawkins, Richard; Tobola, Allison

doi:10.1016/j.jse.2010.03.014

« Previous Next »Journal of Shoulder and Elbow Surgery
Volume 19, Issue 6 , Pages 795-801, September 2010

Positive outcomes with intra-articular glenohumeral injections are independent of accuracy

Eric J. Hegedus, DPT, MHSc
- Physical Therapy Division, Department of Community and Family Medicine, Duke University School of Medicine, NC
- Reprint requests: Eric J. Hegedus, DPT, MHSc, Associate Professor and Medical Director, Doctor of Physical Therapy Division, Department of Community and Family Medicine, Duke University School of Medicine, Durham, NC 27708.
John Zavala, MD
- Steadman Hawkins Clinic of the Carolinas, Greenville Hospital System, Greenville, SC
Michael Kissenberth, MD
- Greenville Hospital System, Greenville, SC
- University of South Carolina School of Medicine, Columbia, SC
Chad Cook, PT, PhD, MBA
- Physical Therapy Division, Department of Community and Family Medicine, Duke University School of Medicine, NC
Kyle Cassas, MD
- Steadman Hawkins Clinic of the Carolinas, Greenville Hospital System, Greenville, SC
- University of South Carolina School of Medicine, Columbia, SC
Richard Hawkins, MD
- Steadman Hawkins Clinic of the Carolinas, Greenville Hospital System, Greenville, SC
- University of South Carolina School of Medicine, Columbia, SC
- University of Colorado, Boulder, CO
- University of Texas Southwestern Medical Center, Dallas, TX
Allison Tobola, MD
- Trinity Mother Frances/University of Texas Health Science Center, Tyler Primary Care Sports Medicine Fellowship Program, Tyler, TX

published online 26 July 2010.

Background

Shoulder pain is a common, costly, and recalcitrant affliction. One treatment for shoulder pain is intra-articular injection of corticosteroid. Clinical opinion is that injection guided by palpation is accurate and effective, and there is some evidence to support a positive effect of injection on pain. However, great controversy exists as to the accuracy of injection by palpation, whether or not accuracy is important, and what the effect is of accuracy on pain.

Methods

We used a blinded, longitudinal observational design of effectiveness in an effort to determine the accuracy of intra-articular injections and the effect of that accuracy on pain and functional outcomes in patients with various shoulder pathologies.

Results

Injection accuracy data were captured on 103 patients. Of the 103 blinded injections, 54 received injections that were identified by fluoroscopy as “in” the capsule, whereas 49 were identified as “outside” the capsule; an accuracy rate of 52.4%. In the 4-week follow up, regardless of group assignment or accuracy of the injection, patients improved significantly (P < .01) from pre- to post-injection. Improvement was typically over by 2.5 points in the Numeric Pain Rating Scale (NPRS) categories, over 8 points on the Short-Form McGill Pain Questionnaire (SFMPQ), and over by 13 points on the Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH).

Discussion

Our accuracy rate was within the range reported in the literature. Improvements in all subjects with regard to pain and self-reported function occurred even in light of a wide variance in subject duration of symptoms, multiple injectors with varied training, a blinded approach to injection, and multiple injection approaches.

Conclusions

The accuracy of the injection does not appear to depend on the experience of the physician and may be irrelevant in treating shoulder pain of multiple origins.

Level of evidence: Level II, Prospective Cohort Study, Treatment Study

Keywords: Intraarticular injection, shoulder, accuracy, pain, function, outcomes