Perspective

Steroid injection significantly relieved shoulder pain at 6 weeks

Early post-injection pain was transient and affected one-third of patients.

Treatment of shoulder pain with steroid injection and physiotherapy significantly improved pain in a sustained manner through 6 weeks, according to study results.

“Our results support that corticosteroid injection is an effective and safe tool in the management of shoulder pain,” Hassan M. T. Fawi, MBBS, MRCS Eng, of University Hospital of Wales, told Orthopedics Today.

Fawi and his colleagues Munier Hossain, MBBS, FRCS (Tr&Orth), and Timothy J.W. Matthews BSc(Hons), MBBS, MD, FRCS (Tr&Orth), studied 116 patients (64.7% were women) with shoulder pain treated with steroid injection and physiotherapy and had them complete a VAS questionnaire for pain prior to the injection. The patients also completed the questionnaire 30 minutes after they receive the injection, daily through day 7 and at 6 weeks following the steroid injection.

The investigators used successful discharge or progression onto surgery at 6 months as a secondary outcome.

Although the results showed there were no significant differences in pain scores 30 minutes after injection, researchers observed a statistically significant reduction in pain scores by day 1, which was maintained at weeks 1 and 6.

Post-injection pain

Overall, Fawi and colleagues found 35.3% of patients experienced post-injection pain or flare, which was defined as a two-point increase in the pre-injection VAS score at any time on days 0 to 7. They also found 7.7% of patients experienced severe post-injection flare defined as an increase in pain score by four points or more. Among patients with post-injection pain or flare, the results showed 24 patients experienced pain within the first 30 minutes of injection. Researchers found 45.83% of those 24 patients remained symptomatic for 3.8 days mean compared to 54.16% of patients who had symptoms solely on the day of the injection.

“Early post-injection pain is a transient phenomenon lasting up to 4 days and affecting one-third of patients,” Fawi said.

The results showed 69.8% of patients were discharged successfully, were satisfied with their current level of symptoms and did not need any further intervention at 6 months post-injection. The mean pre-injection pain VAS score improved from 6.1 points to 3.5 points among the successfully discharged patients.

In addition, 25% of patients either had surgery or were listed for surgery.

Future management

“The response to the injection at 6 weeks should help guide the patient’s future management without the need for further delay,” Fawi said.

Various rates of steroid flare have been discussed anecdotally, Fawi said. However, he said, this was the first study to quantify the ‘steroid flare’ effect methodically and it allows surgeons to provide more accurate answers to their patients.

“We are happy, as well, that we demystified the myth about ‘no pain, no gain’ in relation to steroid flare post-shoulder injections, where developing a flare or not was not related to the final outcome, good or bad.” Fawi said. – by Casey Tingle

Disclosure: Fawi reports no relevant financial disclosures.

Treatment of shoulder pain with steroid injection and physiotherapy significantly improved pain in a sustained manner through 6 weeks, according to study results.

“Our results support that corticosteroid injection is an effective and safe tool in the management of shoulder pain,” Hassan M. T. Fawi, MBBS, MRCS Eng, of University Hospital of Wales, told Orthopedics Today.

Fawi and his colleagues Munier Hossain, MBBS, FRCS (Tr&Orth), and Timothy J.W. Matthews BSc(Hons), MBBS, MD, FRCS (Tr&Orth), studied 116 patients (64.7% were women) with shoulder pain treated with steroid injection and physiotherapy and had them complete a VAS questionnaire for pain prior to the injection. The patients also completed the questionnaire 30 minutes after they receive the injection, daily through day 7 and at 6 weeks following the steroid injection.

The investigators used successful discharge or progression onto surgery at 6 months as a secondary outcome.

Although the results showed there were no significant differences in pain scores 30 minutes after injection, researchers observed a statistically significant reduction in pain scores by day 1, which was maintained at weeks 1 and 6.

Post-injection pain

Overall, Fawi and colleagues found 35.3% of patients experienced post-injection pain or flare, which was defined as a two-point increase in the pre-injection VAS score at any time on days 0 to 7. They also found 7.7% of patients experienced severe post-injection flare defined as an increase in pain score by four points or more. Among patients with post-injection pain or flare, the results showed 24 patients experienced pain within the first 30 minutes of injection. Researchers found 45.83% of those 24 patients remained symptomatic for 3.8 days mean compared to 54.16% of patients who had symptoms solely on the day of the injection.

“Early post-injection pain is a transient phenomenon lasting up to 4 days and affecting one-third of patients,” Fawi said.

The results showed 69.8% of patients were discharged successfully, were satisfied with their current level of symptoms and did not need any further intervention at 6 months post-injection. The mean pre-injection pain VAS score improved from 6.1 points to 3.5 points among the successfully discharged patients.

In addition, 25% of patients either had surgery or were listed for surgery.

Future management

“The response to the injection at 6 weeks should help guide the patient’s future management without the need for further delay,” Fawi said.

Various rates of steroid flare have been discussed anecdotally, Fawi said. However, he said, this was the first study to quantify the ‘steroid flare’ effect methodically and it allows surgeons to provide more accurate answers to their patients.

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“We are happy, as well, that we demystified the myth about ‘no pain, no gain’ in relation to steroid flare post-shoulder injections, where developing a flare or not was not related to the final outcome, good or bad.” Fawi said. – by Casey Tingle

Disclosure: Fawi reports no relevant financial disclosures.

    Perspective
    Joshua D. Harris

    Joshua D. Harris

    Fawi and colleagues reported on 116 adults (65% were female; mean age: 61 years) who underwent shoulder injection (methylprednisolone and lidocaine or bupivacaine; subacromial space 72%, glenohumeral joint 21%; acromioclavicular joint 7%) for multiple causes. They measured the incidence of flare reaction following injection, defined as two-point increase in pre-injection VAS 0 to 7 days post-injection. The two-point difference was based on the minimal clinically important difference in VAS pain. Statistically significant differences were observed at 1 day (0.7 VAS points), and maintained after 1 week (1.9 points) and 6 weeks (two points). Thirty-five percent of subjects experienced flare reaction (mean 3.9 days symptoms; range 1 day to 7 days). Fifty-nine percent of those with a flare experienced it within the first 30 minutes. These findings are similar to those of other upper extremity conditions associated with pain, and there is a similar incidence of flare (approximately one-third) and duration (less than 1 week of symptoms) without impact on eventual statistically significant and clinically relevant VAS improvements in most patients. Steroid flare, due to microcrystal-induced synovitis, can occur after any steroid injection, but is more common in water-insoluble preparations (methylprednisolone, triamcinolone) than soluble preparation (dexamethasone, betamethasone).

    This study mandates that clinicians administering steroid injections understand the flare differential diagnosis, especially vs. septic arthritis, which has later onset (not within first 30 minutes), is more severe (more than two VAS points) and has worsening pain (never resolves within a couple days) with the inability to passively tolerate joint motion and positive synovial fluid analysis (elevated leukocyte count, microorganism presence), as their outcomes are distinctly different (flare spontaneously resolves; septic arthritis is a surgical emergency).

    • Joshua D. Harris, MD
    • Houston Methodist Hospital Houston

    Disclosures: Harris reports no relevant financial disclosures.

    Perspective
    Ryan T. Bicknell

    Ryan T. Bicknell

    This is a prospective cohort study of 116 patients who underwent physiotherapy and a corticosteroid and local anesthetic injection of the shoulder in several different locations, for a variety of diagnoses, with no control group for comparison. Due to these limitations, it is difficult to make conclusions regarding the reason for relief of symptoms, whether the improvement was related to physiotherapy, the injection of local anesthetic or corticosteroid, or simply improvement with time.

    However, some general conclusions can be drawn from this study. First, the authors found a significant improvement in VAS score from pre-injection to day 1, day 7 and 6 weeks. At 6 months, 70% of patients were satisfied and 25% went on to have surgery. Therefore, we can conclude that a 6-month course of nonoperative treatment including physiotherapy and a corticosteroid/local anesthetic injection may be successful in approximately 70% of patients presenting with shoulder pain attributable to a variety of shoulder diagnoses.

    Second, one-third of patients experienced a post-injection increase in pain (ie, flare reaction) within 7 days. Therefore, we can conclude there is an approximate one-in-three chance of experiencing an acute worsening of pain (ie, flare reaction) in the first few days after a shoulder corticosteroid injection, but this pain is likely to resolve within 7 days.

    Finally, none of the injections were complicated by infection or other complications. So, it appears that injection of corticosteroid in the shoulder has a low risk of infection or other complications.

    • Ryan T. Bicknell, MD
    • Associate professor Queen's University Kingston, Ontario

    Disclosures: Bicknell reports no relevant financial disclosures.