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Three Part Question

In [patients presenting with supraspinatus tendinitis] does [local steroid injection] [relieve pain and reduce time to recovery]

Clinical Scenario

A 56 year old lady present in Emergency Department with a history of severe pain in his right shoulder following a busy day working in his garden. She had pain on resisted abduction and tenderness over supraspinatus tendon.

Search Strategy

Medline 1951-May 2005 using dialog (datastar)
[supraspinatus or tendonitis] AND [glucocorticoids#.W.DE. or methylprednisolone#.W.DE. or triamcinolone acetonide#.W.DE] AND [injection$]

Search Outcome

45 papers were identified of which 3 were relevant and formed the subject of this review.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Valtonen EJ 1976 Finland	60 patients in outpatient (Rheumatology clinic) with supraspinatus tendonitis Comparing triamcinolon acetonide versus methyl-Prednisolone	Clinical trial	Pain at 8 weeks	Triam. 3.83 to 1.41 p 0.001. Methyl 3.77 to 1.55 p 0.001. Triam 50% vs mthyl 41% NS between two drugs in reducing pain.	No randomisation No power calculation Not blinded Not in ED setting Side effects: Triam was more painful than methylprednisolone 33% triam required 2nd injection versus 63% in meth. Arm.
			Localised tenderness at 8 weeks	Triam 3.30 to 0.96 p 0.001. Methyl 3.17 to 0.45 p 0.01. Triam 29% vs methyl 14%. NS between two drugs.
			Limitation of motion	Triam 2.90 to 0.78 p 0.001. Methyl 3.13 to 0.85 p 0.001. Triam 27% vs 27%. NS between two drugs.
			Disturbance of sleep	Triam 3.33 to 1.17 p 0.001. Methyl 3.37 to 1.20 p 0.001. Triam 35% vs methyl 36%. NS between two drugs.
Valtonen EJ 1978 Finland	180patients A- 90 pts received local injection of 6 mg betamethasone B- 60 pts intramuscular 6 mg betamethasone C- 30 pts received IM saline Comparing subacromial and gluteal single injection with placebo	Clinical trial	Pain relief, functional improvement at 1, 2, 4 weeks. Diff A-B	At (1) week: NS. At (2) week: NS. At (4) week: NS.	Not randomised Not powered Loss of follow up
			Diff A-C	At (1) week: 0.01
Withrington et al 1985 England	25 pts Rheumatology clinic Group 1 -12 pts received local injection of 80 mg (2ml) methyl prednisolone plus 2ml of 2% lignocaine. Group 2 -13 pts received 4 mls of 0.09% Nacl	Clinical trial	Shoulder movements and pain assessment at presentation 2 weeks and 8 weeks. Group 1.	7 pts responded at (2) weeks (two relapsed at 8 weeks). Mean improvements in VAS of 3.71 cm between (0) and (20 weeks) P > 0.05	Small trial Not powered Placebo vs methylpred. and local effect
			Group 2.	4 pts responded at (2) weeks (1 pt relapsed at 8 weeks). Mean improvement in VAS of 1.16 cm at (0) and (2) weeks. P > 0.05

Comment(s)

Only three studies were found of which all go back to mid-seventies. They were of low quality to produce evidence supporting this clinical practice.

Clinical Bottom Line

Local hospital policy to be followed regarding the treatment of this clinical condition.

References

1. Valtonen EJ. Subacromial Triamcinolone Hexacetonide and Methylprednisolone Injections in Treatment of Supraspinam Tendinitis. Scand J Rheumatology suppl. 16.1976.
2. Valtonen EJ. Double Acting Betamethasone (Celestone Chonodose) in the Treatment of Supraspinatus Tendinitis. J Int Med Res. 1978;6:463.
3. Withrington R H, Girgis F L, Seifert M H. A Placebo-Controlled Trial of Steroid Injections in the Treatment of Supraspinatus Tendonitis. Scand J Rheumatology 1985;14:76-78.