Determination of Steroid Injection Sites Using Lidocaine Test in Adhesive Capsulitis: A Prospective Randomized Clinical Trial Sang Jun Kim, MD, PhD,1 Albert O. Gee, MD,2 Jung Min Hwang, MD,1 Jeong Yi Kwon, MD, PhD1 1
Department of Physical and Rehabilitation Medicine, Sungkyunkwan University School of Medicine, Samsung Medical Center, Samsung Medical Center, Gangnam-Gu, Irwonro, 50th, Seoul 135-710, Republic of Korea 2 Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, WA, USA Received 10 January 2014; accepted 9 June 2014
ABSTRACT: Background. To validate the usefulness of subacromial bursa lidocaine for determination of the therapeutic steroid injection site in patients with adhesive capsulitis Methods. Ninety-two patients with adhesive capsulitis were randomly divided into the LC (lidocaine test) group (n 5 46), in which LC injection was performed at the subacromial bursa prior to therapeutic steroid injection, and GH (glenohumeral) group (n 5 46), in which the steroid was injected into the GH. Patients in the LC group received steroid injection at the subacromial bursa or GH according to the result of the LC. Both groups underwent the same exercise protocol. Improvement of the shoulder pain was checked at 2 weeks and 3 months postinjection and expressed on an ordinal scale. Passive range of motion was recorded preinjection, and 2 weeks and 3 months postinjection. Results. Two weeks postinjection, 37 patients expressed “much improved” and 7 patients expressed “slightly improved” pain levels in the LC group, whereas 18 patients each expressed “much improved” and “slightly improved” pain levels in the GH group, which was significantly different (p < 0.01). This difference was maintained 3 months postinjection (p < 0.01). Passive range of motion in all directions improved significantly 3 months postinjection in both the LC and GH groups (p < 0.01). However, there was no significant difference between the LC and GH groups. Conclusions. We found that subacromial lidocaine injection prior to steroid injection resulted in better improvement of pain than conventional GH injection C 2014 Wiley for patients with adhesive capsulitis. V Correspondence to: S. J. Kim
Periodicals, Inc. J Clin Ultrasound 00:000–000, 2014; Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/jcu.22201 Keywords: adhesive capsulitis; lidocaine; subacromial bursa; glenohumeral joint
A
dhesive capsulitis is characterized by shoulder pain and significant restriction of both active and passive shoulder motion, in the absence of a known intrinsic shoulder disorder.1 Arthrography of the shoulder in patients with adhesive capsulitis revealed evidence of contracted axillary fold, reduced glenohumeral (GH) joint volume, and obliteration of subcoracoid fat between the coracohumeral ligament and the coracoid process.2 The pathologic findings in adhesive capsulitis included a chronic inflammatory infiltrate and subsynovial fibrosis as determined from biopsies taken from patients with the disease.3 It can often be difficult to isolate the source of shoulder pain. This is because the shoulder is composed of numerous structures including the subacromial bursa, rotator cuff muscles and tendons, shoulder capsule and labrum, and GH ligaments, which may all be a source of pain. A number of physical tests are used to diagnose the pain source, but they unfortunately show low sensitivity or specificity.4 Imaging studies such as MRI and ultrasound may reveal pathologic findings in the shoulder, but these pathologic findings do not always correspond to the pain source. Abnormal findings involving the rotator cuff or adjacent subacromial bursa
C 2014 Wiley Periodicals, Inc. V
VOL. 00, NO. 00, MONTH 2014
1
KIM ET AL
are often detected with advanced imaging when the patient is asymptomatic.5 The actual pain source in patients with adhesive capsulitis remains unknown because its pathophysiology is not yet well understood.2 Despite this, the standard placement of local steroid treatment is within the GH, in order to address the inflammation within the joint capsule. Recently, however, steroid injection into the subacromial bursa has been reported to have a similar effect to the GH injection in effective treatment of adhesive capsulitis.6,7 If the source of pain in adhesive capsulitis is restricted to either the GH or the subacromial bursa, determining the accurate injection site will be critical in reducing the pain and treating the disorder. Chronic rotator cuff or subacromial bursa problem itself may cause secondary adhesive capsulitis because of altered kinematics and persistent restricted motion of the painful shoulder.8,9 However, considering that subacromial bursa injection was effective even in primary adhesive capsulitis without diagnosed rotator cuff or subacromial bursa problems,7 we can infer that the subacromial bursa is a potential primary pain source in primary adhesive capsulitis. Imaging studies such as ultrasound and MRI cannot determine the proper injection site (subacromial bursa or GH) when no definite abnormality is detected, or the abnormality detected in the imaging studies is asymptomatic. In this case, the LC (lidocaine test) will be helpful to determine the accurate injection site. Steroid injections have major side effects ranging from temporarily elevated glucose levels to tendon rupture, unlike lidocaine injection.10 Thus, lidocaine injection test prior to steroid injection will be helpful in locating the accurate treatment site for adhesive capsulitis. The aim of this study was to validate whether the practice of a two-staged injection was more effective than the conventional GH injection in treating adhesive capsulitis. We accordingly tested our hypothesis that the two-staged injection has a higher success rate than the current standard of GH intra-articular steroid injection. In addition, the two-staged injection can potentially prevent the inefficient use of steroid, in treating pain caused by adhesive capsulitis. PATIENTS AND METHODS
We recruited patients who presented with shoulder pain at our outpatient department from December 2011 to January 2013. The 2
inclusion criteria for patients were the diagnosis of adhesive capsulitis by physical examination and image studies. Neer test, Kennedy-Hawkins test, and bear-hug test were done, and the passive ranges of motion (PROMs) in flexion, abduction, internal rotation, and external rotation were measured by physical examination. The diagnosis of adhesive capsulitis was made when the patient had shoulder pain and decreased range of motion and when other shoulder diseases were excluded. Rotator cuff tear was diagnosed through the sonographic examination and physical examinations, including drop arm sign, empty can test, and bearhug test. Glenohumeral arthritis was diagnosed through the simple radiographs. Subacromial bursitis was diagnosed when the Neer and Kennedy-Hawkins tests were positive and bursa swelling or increased bursal wall thickness was observed on ultrasound. Exclusion criteria included prior shoulder surgery, prior steroid injection (within 3 months), immune compromised condition, bleeding disorder, and also patients who could not explain their pain status accurately due to poor cognitive function. All the patients underwent sonographic imaging studies of the involved shoulder before any treatment was provided. An ultrasound machine (Voluson E6, Siemens, Germany) equipped with a linear probe (Model No. 11L-D, 3.0–12.0 MHz) for musculoskeletal structures was used for this examination. Rotator cuff tendons and muscles, bicipital groove, subacromial bursa, and glenoid labrum were examined by ultrasound. At this point, based on sonographic examination, patients with rotator cuff or labral tears, subacromial subdeltoid bursa swelling, or bursal wall-thickening were excluded from the study. This confirmed that patients had only adhesive capsulitis without any subacromial or subdeltoid problem. Numeric rating scale (NRS) during the shoulder motion was evaluated prior to injection. The patients who met the inclusion criteria and consented to participate in this study were randomly divided into two groups, using random sampling digits. The LC group received 2 ml of 1% lidocaine injection into the subacromial space by sonographic imaging guidance. About 30 seconds after this injection, we asked the patients to simulate the pain-evoking position several times and to report the degree of pain reduction, as a percentage of the pain at the same position, prior to lidocaine injection. This procedure lasted several minutes, which would be enough time to check the action of JOURNAL OF CLINICAL ULTRASOUND
LIDOCAINE TEST IN ADHESIVE CAPSULITIS
locally infiltrated 1% lidocaine. If the reduction of pain was more than 50%, then the second injection of the steroid solution (ie, 1 ml of 40 mg triamcinolone acetonide [Triamcinolone, Dongkwang Pharmacy] mixed with 4 ml of 1% lidocaine) was applied at the same site. If pain reduction was less than 50%, the same amount of steroid was injected at the GH. Lidocaine test injection was done at the subacromial bursa rather than at the GH because we wanted to estimate the number of patients with adhesive capsulitis who showed pain reduction by subacromial bursa injection. The GH group received the same steroid injection at the GH without any LC. We used a total of 5 ml of steroid and lidocaine, which is more than the usual volume for shoulder injection (2–3 ml), because we expected an expansion effect on the contracted capsules in adhesive capsulitis. Subacromial bursa and GH injections were performed with sonographic guidance. For the subacromial bursa injection, a 22-gauge needle was inserted into the subacromial bursa, which shows a thin hypoechogenic band in a longitudinal view of the supraspinatus muscle near the acromion. Then, either lidocaine or steroid solution was slowly injected into the subacromial bursa. The steroid injection into the GH was performed using the posterior approach after finding the posterior glenoid labrum, as described in a previous study.11 All the injections were performed by one physiatrist who had prior experience of 10,000 cases of subacromial bursa and GH injections. Improvement of the shoulder pain was evaluated 2 weeks and 3 months postinjection and expressed in an ordinal scale (0 5 “not improved,” 2 5 “much improved”) as reported in a previous study.12 If the pain was reduced to 50% compared with the initial pain, it was considered “much improved” and if < 50%, then it was considered “slightly improved.” At 2 weeks postinjection, all patients were introduced to two experienced physical therapists to learn home exercise protocols for stretching and strengthening the shoulder girdle muscles. They were asked to do it by themselves for 3 months. Two therapists who shared their standardized exercise protocols were blinded to the patient groups. PROMs in flexion, abduction, and internal and external rotation were measured preinjection, and 2 weeks and 3 months postinjection. None of these patients received other treatments, including physical therapy and another injection at other hospitals during the study period. VOL. 00, NO. 00, MONTH 2014
We compared the improvement of the pain and the change of PROMs postinjection between the LC and GH groups, by Wilcoxon rank sum, and repeated measures analysis of variance (RM-ANOVA) tests with post-hoc analysis for each parameter. Bonferroni correction was adopted using the corrected p values multiplied by the number of statistical analyses to prevent a false positive result caused by multiple statistical analyses. The primary statistical analysis was based on the intention-to-treat principle using the improvement of the pain 3 months postinjection as the primary endpoint. The missing data were managed using the lastobservation-carried-forward technique. Necessary sample size was 42 in each group, based on our preliminary results in which the difference of average improvement scale between 2 groups was 0.3 when type 1 and 2 errors were assumed to be 0.05 and 0.1, respectively. All statistical analyses were done with SPSS 20.0 software (IBM, Armonk, NY, USA). We explained the purpose and procedures of this study to all patients who participated and obtained informed oral consent. We conformed to the ethical guidelines of the 1975 Declaration of Helsinki and the study was approved by our Institutional Review Board.
RESULTS
A total of 675 patients visited our department for shoulder pain during the study period and 192 patients were diagnosed as having adhesive capsulitis. Among them, 92 patients met the criteria of our study and all of them consented to participate. Forty-six patients were allocated to the LC group and the rest to the GH group (Figure 1). The ratio of male-to-female was 24–22 (52.2%) in the LC group and 18–28 (39.1%) in the GH group, which did not show any significant difference (p 5 0.30). The average age of the patients in the LC group (55.5612.4, mean 6 SD) was not significantly different from that in the GH group (56.16 7.8, mean 6 SD) (p 5 0.76). Initial NRS did not show any significant difference between the groups (p 5 0.55). There was no significant difference in baseline PROM between the LC and GH groups. In initial sonographic findings, four patients in the LC group and five patients in the GH group showed supraspinatus tendinosis, which was not significantly different (p 5 1.00). Baseline characteristics of patients were presented in Table 1. 3
KIM ET AL
We compared the findings of physical examination at the initial visit (ie, Neer test, Kennedy-Hawkins test, and bear-hug test). Twenty-eight patients in the LC group and 21 patients in the GH group showed positive Neer test, which was not significantly different between groups (p 5 0.21). Kennedy-Hawkins test results did not reveal any significant difference between the groups (p 5 0.40). Bear-hug test was positive in three patients in the LC group and in two patients in the GH group. Two weeks after the injection, 37 patients expressed “much improved” and 7 patients expressed “slightly improved” pain levels in the
FIGURE 1. Flow diagram of patient recruitment was based on CONSORT (Consolidated Standards of Reporting Trials). Ninety-two patients met the criteria of our study and all of them consented to participate in the study.
LC group, while 18 and 18 patients expressed “much improved” and “slightly improved” pain levels, respectively, in the GH group, which was significantly different (Wilcoxon rank sum p < 0.01). This difference was maintained 3 months postinjection (Wilcoxon rank sum p < 0.01). One patient in the LC group and three patients in the GH group were lost to follow-up. PROMs in all directions improved significantly 3 months postinjection in both the LC and the GH groups; all the p values in each group were 0.001 by RM-ANOVA test. However, there was no significant difference between groups by RM-ANOVA tests (p 5 0.19 in flexion, p 5 0.22 in abduction, p 5 0.97 in internal rotation, and p 5 0.31 in external rotation). The changes of PROM are presented in Figure 2. Among 46 patients in the LC group, 23 patients received the steroid injection into the GH and 23 patients into the subacromial bursa. Initial PROMs in flexion and abduction were not significantly different between two subgroups of different injection sites (p 5 0.95 and 0.35), but the internal and external rotations in the GH injection subgroup were significantly less than those in the subacromial injection subgroup (p 5 0.01 and p < 0.01) (Figure 3). After the injection, the changes of PROM in flexion and abduction were not significantly different between injection sites within the LC group (p 5 0.98 in flexion and 0.71 in abduction). However, there were subgroup differences between injection sites in the changes of internal and
TABLE 1 Baseline Characteristics of Randomly Allocated Patients with Adhesive Capsulitis GH Group LC Group Age, years Gender, male: female NRS score Physical tests: positive number (% in total) Neer test Hawkins test Bear-hug test Range of motion Flexion Abduction Internal rotation External rotation Sonographic findings: positive number (% in total) Supraspinatus tendinosis Calcification
GH Injection (n 5 23)
SA Injection (n 5 23)
Total (n 5 46)
GH Injection (n 5 46)
58.8 6 13.0 12:11 6.4 6 1.3
52.1 6 10.9 12:11 6.3 6 1.2
55.5 6 12.4 24:22 6.3 6 1.2
56.1 6 7.8 18:28 6.2 6 1.2
13 (56.5) 9 (39.1) 0 (0.0)
15 (65.2) 13 (56.5) 3 (13.0)
28 (60.9) 22 (47.8) 3 (6.5)
21 (45.7) 17 (37.0) 2 (4.3)
93.9 6 25.5 66.1 6 33.9 41.3 6 19.1 42.2 6 18.1
93.5 6 17.2 73.9 6 20.4 58.0 6 22.8 61.3 6 17.3
93.7 6 21.5 70.0 6 28.0 49.7 6 22.5 51.7 6 20.0
86.2 6 25.6 66.0 6 17.4 47.8 6 16.5 48.9 6 18.3
2 (8.7) 2 (8.7)
2 (8.7) 0 (0.0)
4 (8.7) 2 (4.3)
5 (10.9) 8 (17.4)
Abbreviations: GH, glenohumeral joint; LC, lidocaine injection test; SA, subacromial bursa.
4
JOURNAL OF CLINICAL ULTRASOUND
LIDOCAINE TEST IN ADHESIVE CAPSULITIS
FIGURE 2. Passive shoulder ranges of motion were increased 3 months postinjection for both the GH and the LC groups. Lower bars are 1 SD of ranges of motion in the GH group and upper bars in the LC group.
FIGURE 3. Passive shoulder ranges of motion were presented for GH and subacromial bursa injection subgroups in the LC group. Lower bars are 1 SD of ranges of motion in GH injection subgroup and upper bars in subacromial bursa injection subgroup. VOL. 00, NO. 00, MONTH 2014
5
KIM ET AL
external rotations (p < 0.01 in internal rotation and p < 0.01 in external rotation). The level of pain reduction was not significantly different between two subgroups of different injection sites within the LC group (Wilcoxon rank sum p 5 0.29 and 0.69 in 2 weeks and 3 months postinjection).
DISCUSSION
We found that a therapeutic steroid injection after determining the injection site (GH or subacromial bursa) with a LC was more effective in reducing pain caused by adhesive capsulitis compared with a standard steroid injection into the GH. The treatment, however, did not affect the level of improvement in terms of range of motion of the shoulder. Lidocaine test injections have been previously used for diagnostic purposes. The LC was used to assist in the diagnosis of full-thickness tear of the supraspinatus tendon13,14 or to exclude GH involvement.15 It has also been used in other parts of the body as well. In the spine, it is often used to determine whether back pain originates from the facet joint before therapeutic steroid injection16 and has been described to determine the source of hip pain from articular or extra-articular pathology.17 Similarly, we believe that this study provided evidence that a LC could increase the success rates of steroid injection in the management of pain from adhesive capsulitis. It may also be useful in preventing multiple, ineffective GH steroid injections with potential side effects, such as hyperglycemia, tendon atrophy, tendon rupture, or osteomyelitis.10 We arbitrarily set the criteria for determining the injection site and classifying the improvement of pain postinjection as a 50% reduction of pain. The rationale was based on the results of a previous study18 in which the criteria used to determine the pain source through the bupivacaine injection were 50% pain reduction. Oh et al7 also used 50% reduction of visual analog scale scores postinjection compared with the initial scores as the criteria of clinical improvement. For the improvement of pain, we used three ordinal scales of pain relief on verbal response, instead of change of NRS. Because adhesive capsulitis is not single dimensional in nature but multidimensional, including discomfort caused by the limitation of motion, it makes the subjective feeling more clinically meaningful 6
than a single number.19 However, to estimate the pain reduction and functional improvement postinjection more accurately, additional scales including SPADI (Shoulder Pain and Disability Index) and ASES (American Shoulder and Elbow Surgeons) score will be necessary. In a preliminary study (data not shown), we found that patients who did not show improvement after the subacromial bursa lidocaine injection showed the improvement after the GH lidocaine injection. Therefore, we did not believe that 2 ml of lidocaine solution injected into the subacromial bursa would affect the pain from GH origin, even though dispersal rates for subacromial bursa and GH injections range from 16 to 19%.20 In the current study, we did not attempt lidocaine injection at the GH in patients who did not show the pain improvement after the subacromial bursa lidocaine injection, because our goal was to reduce the number of injections. Future studies to find the pain source other than the subacromial bursa and GH will supplement our current understanding. We found that lidocaine injection at subacromial bursa was responsive in 50% of patients with adhesive capsulitis (23 of 46 patients in the LC group). This suggested that the pain source of adhesive capsulitis might be emanating from the subacromial bursa. We excluded the patients who had evidence of subacromial bursa swelling or wall-thickening on sonographic imaging study with positive signs of Neer and Hawkins tests. We found that of four patients with supraspinatus tendinopathy, two patients were responsive to subacromial bursa lidocaine injection, while two patients were unresponsive. Therefore, it is likely that concordant subacromial pathology might not affect the responsiveness of subacromial bursa lidocaine injection. To date, there is no clear explanation why steroid injection into the subacromial bursa would be effective in reducing pain caused by adhesive capsulitis. Although the subacromial bursa is separated from the GH by the superior aspect of the rotator cuff, it is possible that the inflammatory mediators can spread from the GH to the subacromial bursa or vice versa through the rotator cuff interval. Alternatively, inflammation may occur widely from the GH to the subacromial space through the supraspinatus muscle or tendon. Because the rotator interval was reportedly involved in a proliferative inflammatory process in adhesive capsulitis,21 this explanation may be plausible. Furthermore, JOURNAL OF CLINICAL ULTRASOUND
LIDOCAINE TEST IN ADHESIVE CAPSULITIS
a recent MRI study22 revealed that thickening of the coracohumeral ligament and joint capsule at the rotator interval were the most characteristic findings in patients with adhesive capsulitis. Our results are also consistent with those from a previous study by Andrieu et al,23 in which subacromial bursography with steroid injection was useful in adhesive capsulitis cases that failed to respond to GH injection. In another study, Oh et al7 revealed that subacromial injection had the same effect as GH injection in adhesive capsulitis, which is also consistent with our findings. Considering that only 24% of patients with adhesive capsulitis showed improvement in pain level after the steroid injection at the GH in a previous study,24 it is likely that the improvement ratio would have increased further, if the injection site were to have been changed to the subacromial space, in unresponsive cases. Patients who received GH injection had more decreased baseline internal and external rotations than those who received subacromial bursa injection in the LC group. This means that patients with adhesive capsulitis with the GH rather than the subacromial space as pain source had more limited internal and external rotation. This was explained by the fact that the problems arising from the GH cause the limitation of all the movement directions, while those arising from the subacromial space limit mainly the flexion and abduction of the shoulder,25,26 rather than the internal and external rotation. In our study, PROM of the shoulder increased at 3 months postinjection in both groups. This could be attributed to self-stretching and strengthening exercises of the shoulder girdle muscles, in addition to the steroid injection.27 Our result of no difference in final PROM between the two groups was possibly due to the same exercise protocols used in both groups. However, we did not investigate the compliance of this self-exercise, which could have biased the range of motion. There are several limitations to our study. Although the patients were randomized, it was not possible to blind the patients to the treatment group because we could not do a LC injection equally in both groups. We were concerned about the ethical implications of a sham LC injection for patients in the GH group. We made an effort to minimize the number of injections (maximum of two) to prevent possible side effects, such as infection, bleeding, and postinjection pain, which made the blinding of VOL. 00, NO. 00, MONTH 2014
patients impossible. This had the potential to bias our results as participants in the LC group who received two-staged injections might have felt that they received more attention (or care) than those who received one injection. Despite the limitations to our study, we believe our findings remain valuable because they suggest the possibility of improving the therapeutic efficacy of steroid injection in adhesive capsulitis. However, future double-blind studies will be necessary to confirm these findings. Another limitation to our study is the possibility that the subacromial test injection within the LC group was more effective as there was a higher number of patients in that subgroup, with shoulder impingement on their physical examination (determined by positive Neer and Hawkins test). It is possible that these patients represented a subgroup of patients who had potentially combined impingement characteristics with adhesive capsulitis. This might explain why the subacromial lidocaine injection together with therapeutic steroid injection provided better relief of pain. Ultrasound ruled out any pathologic changes in the subacromial space and thus minimized inclusion of any true impingement patients in this study, but it is possible that patients with mild or “subclinical” shoulder impingement pain may have been undiagnosed on ultrasound. The last limitation was that, although not statistically significant, there were a higher number of men in the LC group (n 5 22) than in the GH group (n 5 16) despite randomization. A previous study28 revealed that women showed better results of a stretching-exercise program than men; hence, this gender difference might have impacted our results. This may require consideration in future studies with this technique. We found that the use of subacromial bursa LC injection to determine the placement of a therapeutic steroid injection resulted in better improvement of pain than conventional GH injection for patients with adhesive capsulitis. In conjunction with a sound physical therapy regimen, this technique may provide for better outcomes in patients with adhesive capsulitis. Further trials in the form of a double-blind study may be warranted to confirm these findings. REFERENCES 1. Zuckerman JD, Rokito A. Frozen shoulder: a consensus definition. J Shoulder Elbow Surg 2011;20: 322.
7
KIM ET AL 2. Hsu JE, Anakwenze OA, Warrender WJ, et al. Current review of adhesive capsulitis. J Shoulder Elbow Surg 2011;20:502. 3. Neviaser AS, Neviaser RJ. Adhesive capsulitis of the shoulder. J Am Acad Orthop Surg 2011;19:536. 4. Alqunaee M, Galvin R, Fahey T. Diagnostic accuracy of clinical tests for subacromial impingement syndrome: a systematic review and meta-analysis. Arch Phys Med Rehabil 2012;93:229. 5. Girish G, Lobo LG, Jacobson JA, et al. Ultrasound of the shoulder: asymptomatic findings in men. AJR Am J Roentgenol 2011;197:W713. 6. Shin SJ, Lee SY. Efficacies of corticosteroid injection at different sites of the shoulder for the treatment of adhesive capsulitis. J Shoulder Elbow Surg 2013;22:521. 7. Oh JH, Oh CH, Choi JA, et al. Comparison of glenohumeral and subacromial steroid injection in primary frozen shoulder: a prospective, randomized short-term comparison study. J Shoulder Elbow Surg 2011;20:1034. 8. Hall LC, Middlebrook EE, Dickerson CR. Analysis of the influence of rotator cuff impingements on upper limb kinematics in an elderly population during activities of daily living. Clin Biomech (Bristol, Avon) 2011;26:579. 9. Almekinders LC. Impingement syndrome. Clin Sports Med 2001;20:491. 10. Brinks A, Koes BW, Volkers AC, et al. Adverse effects of extra-articular corticosteroid injections: a systematic review. BMC Musculoskelet Disord 2010;11:206. 11. Zwar RB, Read JW, Noakes JB. Sonographically guided glenohumeral joint injection. AJR Am J Roentgenol 2004;183:48. 12. Salaffi F, Stancati A, Silvestri CA, et al. Minimal clinically important changes in chronic musculoskeletal pain intensity measured on a numerical rating scale. Eur J Pain 2004;8:283. 13. Bak K, Sorensen AK, Jorgensen U, et al. The value of clinical tests in acute full-thickness tears of the supraspinatus tendon: does a subacromial lidocaine injection help in the clinical diagnosis? A prospective study. Arthroscopy 2010;26:734. 14. Park JY, Lee WS, Lee ST. The strength of the rotator cuff before and after subacromial injection of lidocaine. J Shoulder Elbow Surg 2008;17(Suppl 1):8S. 15. Anderson BC. Evaluation of the patient with shoulder complaints. UpToDate. [updated 2014 Feb 24; cited 2013 Feb 10]. Available from: http://
8
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
www.uptodate.com/contents/evaluation-of-the-patientwith-shoulder-complaints. Schwarzer AC, Derby R, Aprill CN, et al. The value of the provocation response in lumbar zygapophyseal joint injections. Clin J Pain 1994;10:309. Kivlan BR, Martin RL, Sekiya JK. Response to diagnostic injection in patients with femoroacetabular impingement, labral tears, chondral lesions, and extra-articular pathology. Arthroscopy 2011; 27:619. Schwarzer AC, Aprill CN, Derby R, et al. Clinical features of patients with pain stemming from the lumbar zygapophysial joints. Is the lumbar facet syndrome a clinical entity? Spine 1994;19:1132. Sloman R, Wruble AW, Rosen G, et al. Determination of clinically meaningful levels of pain reduction in patients experiencing acute postoperative pain. Pain Manag Nurs 2006;7:153. Hanchard N, Shanahan D, Howe T, et al. Accuracy and dispersal of subacromial and glenohumeral injections in cadavers. J Rheumatol 2006;33:1143. Petchprapa CN, Beltran LS, Jazrawi LM, et al. The rotator interval: a review of anatomy, function, and normal and abnormal MRI appearance. AJR Am J Roentgenol 2010;195:567. Zhao W, Zheng X, Liu Y, et al. An MRI study of symptomatic adhesive capsulitis. PLoS One 2012; 7:e47277. Andrieu V, Dromer C, Fourcade D, et al. Adhesive capsulitis of the shoulder: therapeutic contribution of subacromial bursography. Rev Rhum Engl Ed 1998;65:771. Bal A, Eksioglu E, Gulec B, et al. Effectiveness of corticosteroid injection in adhesive capsulitis. Clin Rehabil 2008;22:503. Michener LA, McClure PW, Karduna AR. Anatomical and biomechanical mechanisms of subacromial impingement syndrome. Clin Biomech (Bristol, Avon) 2003;18:369. Hinterwimmer S, Von Eisenhart-Rothe R, Siebert M, et al. Influence of adducting and abducting muscle forces on the subacromial space width. Med Sci Sports Exerc 2003;35:2055. De Carli A, Vadala A, Perugia D, et al. Shoulder adhesive capsulitis: manipulation and arthroscopic arthrolysis or intra-articular steroid injections? Int Orthop 2012;36:101. Griggs SM, Ahn A, Green A. Idiopathic adhesive capsulitis. A prospective functional outcome study of nonoperative treatment. J Bone Joint Surg Am 2000;82:1398.
JOURNAL OF CLINICAL ULTRASOUND
Department of Physical and Rehabilitation Medicine, Sungkyunkwan University School of Medicine, Samsung Medical Center, Samsung Medical Center, Gangnam-Gu, Irwonro, 50th, Seoul 135-710, Republic of Korea 2 Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, WA, USA Received 10 January 2014; accepted 9 June 2014
ABSTRACT: Background. To validate the usefulness of subacromial bursa lidocaine for determination of the therapeutic steroid injection site in patients with adhesive capsulitis Methods. Ninety-two patients with adhesive capsulitis were randomly divided into the LC (lidocaine test) group (n 5 46), in which LC injection was performed at the subacromial bursa prior to therapeutic steroid injection, and GH (glenohumeral) group (n 5 46), in which the steroid was injected into the GH. Patients in the LC group received steroid injection at the subacromial bursa or GH according to the result of the LC. Both groups underwent the same exercise protocol. Improvement of the shoulder pain was checked at 2 weeks and 3 months postinjection and expressed on an ordinal scale. Passive range of motion was recorded preinjection, and 2 weeks and 3 months postinjection. Results. Two weeks postinjection, 37 patients expressed “much improved” and 7 patients expressed “slightly improved” pain levels in the LC group, whereas 18 patients each expressed “much improved” and “slightly improved” pain levels in the GH group, which was significantly different (p < 0.01). This difference was maintained 3 months postinjection (p < 0.01). Passive range of motion in all directions improved significantly 3 months postinjection in both the LC and GH groups (p < 0.01). However, there was no significant difference between the LC and GH groups. Conclusions. We found that subacromial lidocaine injection prior to steroid injection resulted in better improvement of pain than conventional GH injection C 2014 Wiley for patients with adhesive capsulitis. V Correspondence to: S. J. Kim
Periodicals, Inc. J Clin Ultrasound 00:000–000, 2014; Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/jcu.22201 Keywords: adhesive capsulitis; lidocaine; subacromial bursa; glenohumeral joint
A
dhesive capsulitis is characterized by shoulder pain and significant restriction of both active and passive shoulder motion, in the absence of a known intrinsic shoulder disorder.1 Arthrography of the shoulder in patients with adhesive capsulitis revealed evidence of contracted axillary fold, reduced glenohumeral (GH) joint volume, and obliteration of subcoracoid fat between the coracohumeral ligament and the coracoid process.2 The pathologic findings in adhesive capsulitis included a chronic inflammatory infiltrate and subsynovial fibrosis as determined from biopsies taken from patients with the disease.3 It can often be difficult to isolate the source of shoulder pain. This is because the shoulder is composed of numerous structures including the subacromial bursa, rotator cuff muscles and tendons, shoulder capsule and labrum, and GH ligaments, which may all be a source of pain. A number of physical tests are used to diagnose the pain source, but they unfortunately show low sensitivity or specificity.4 Imaging studies such as MRI and ultrasound may reveal pathologic findings in the shoulder, but these pathologic findings do not always correspond to the pain source. Abnormal findings involving the rotator cuff or adjacent subacromial bursa
C 2014 Wiley Periodicals, Inc. V
VOL. 00, NO. 00, MONTH 2014
1
KIM ET AL
are often detected with advanced imaging when the patient is asymptomatic.5 The actual pain source in patients with adhesive capsulitis remains unknown because its pathophysiology is not yet well understood.2 Despite this, the standard placement of local steroid treatment is within the GH, in order to address the inflammation within the joint capsule. Recently, however, steroid injection into the subacromial bursa has been reported to have a similar effect to the GH injection in effective treatment of adhesive capsulitis.6,7 If the source of pain in adhesive capsulitis is restricted to either the GH or the subacromial bursa, determining the accurate injection site will be critical in reducing the pain and treating the disorder. Chronic rotator cuff or subacromial bursa problem itself may cause secondary adhesive capsulitis because of altered kinematics and persistent restricted motion of the painful shoulder.8,9 However, considering that subacromial bursa injection was effective even in primary adhesive capsulitis without diagnosed rotator cuff or subacromial bursa problems,7 we can infer that the subacromial bursa is a potential primary pain source in primary adhesive capsulitis. Imaging studies such as ultrasound and MRI cannot determine the proper injection site (subacromial bursa or GH) when no definite abnormality is detected, or the abnormality detected in the imaging studies is asymptomatic. In this case, the LC (lidocaine test) will be helpful to determine the accurate injection site. Steroid injections have major side effects ranging from temporarily elevated glucose levels to tendon rupture, unlike lidocaine injection.10 Thus, lidocaine injection test prior to steroid injection will be helpful in locating the accurate treatment site for adhesive capsulitis. The aim of this study was to validate whether the practice of a two-staged injection was more effective than the conventional GH injection in treating adhesive capsulitis. We accordingly tested our hypothesis that the two-staged injection has a higher success rate than the current standard of GH intra-articular steroid injection. In addition, the two-staged injection can potentially prevent the inefficient use of steroid, in treating pain caused by adhesive capsulitis. PATIENTS AND METHODS
We recruited patients who presented with shoulder pain at our outpatient department from December 2011 to January 2013. The 2
inclusion criteria for patients were the diagnosis of adhesive capsulitis by physical examination and image studies. Neer test, Kennedy-Hawkins test, and bear-hug test were done, and the passive ranges of motion (PROMs) in flexion, abduction, internal rotation, and external rotation were measured by physical examination. The diagnosis of adhesive capsulitis was made when the patient had shoulder pain and decreased range of motion and when other shoulder diseases were excluded. Rotator cuff tear was diagnosed through the sonographic examination and physical examinations, including drop arm sign, empty can test, and bearhug test. Glenohumeral arthritis was diagnosed through the simple radiographs. Subacromial bursitis was diagnosed when the Neer and Kennedy-Hawkins tests were positive and bursa swelling or increased bursal wall thickness was observed on ultrasound. Exclusion criteria included prior shoulder surgery, prior steroid injection (within 3 months), immune compromised condition, bleeding disorder, and also patients who could not explain their pain status accurately due to poor cognitive function. All the patients underwent sonographic imaging studies of the involved shoulder before any treatment was provided. An ultrasound machine (Voluson E6, Siemens, Germany) equipped with a linear probe (Model No. 11L-D, 3.0–12.0 MHz) for musculoskeletal structures was used for this examination. Rotator cuff tendons and muscles, bicipital groove, subacromial bursa, and glenoid labrum were examined by ultrasound. At this point, based on sonographic examination, patients with rotator cuff or labral tears, subacromial subdeltoid bursa swelling, or bursal wall-thickening were excluded from the study. This confirmed that patients had only adhesive capsulitis without any subacromial or subdeltoid problem. Numeric rating scale (NRS) during the shoulder motion was evaluated prior to injection. The patients who met the inclusion criteria and consented to participate in this study were randomly divided into two groups, using random sampling digits. The LC group received 2 ml of 1% lidocaine injection into the subacromial space by sonographic imaging guidance. About 30 seconds after this injection, we asked the patients to simulate the pain-evoking position several times and to report the degree of pain reduction, as a percentage of the pain at the same position, prior to lidocaine injection. This procedure lasted several minutes, which would be enough time to check the action of JOURNAL OF CLINICAL ULTRASOUND
LIDOCAINE TEST IN ADHESIVE CAPSULITIS
locally infiltrated 1% lidocaine. If the reduction of pain was more than 50%, then the second injection of the steroid solution (ie, 1 ml of 40 mg triamcinolone acetonide [Triamcinolone, Dongkwang Pharmacy] mixed with 4 ml of 1% lidocaine) was applied at the same site. If pain reduction was less than 50%, the same amount of steroid was injected at the GH. Lidocaine test injection was done at the subacromial bursa rather than at the GH because we wanted to estimate the number of patients with adhesive capsulitis who showed pain reduction by subacromial bursa injection. The GH group received the same steroid injection at the GH without any LC. We used a total of 5 ml of steroid and lidocaine, which is more than the usual volume for shoulder injection (2–3 ml), because we expected an expansion effect on the contracted capsules in adhesive capsulitis. Subacromial bursa and GH injections were performed with sonographic guidance. For the subacromial bursa injection, a 22-gauge needle was inserted into the subacromial bursa, which shows a thin hypoechogenic band in a longitudinal view of the supraspinatus muscle near the acromion. Then, either lidocaine or steroid solution was slowly injected into the subacromial bursa. The steroid injection into the GH was performed using the posterior approach after finding the posterior glenoid labrum, as described in a previous study.11 All the injections were performed by one physiatrist who had prior experience of 10,000 cases of subacromial bursa and GH injections. Improvement of the shoulder pain was evaluated 2 weeks and 3 months postinjection and expressed in an ordinal scale (0 5 “not improved,” 2 5 “much improved”) as reported in a previous study.12 If the pain was reduced to 50% compared with the initial pain, it was considered “much improved” and if < 50%, then it was considered “slightly improved.” At 2 weeks postinjection, all patients were introduced to two experienced physical therapists to learn home exercise protocols for stretching and strengthening the shoulder girdle muscles. They were asked to do it by themselves for 3 months. Two therapists who shared their standardized exercise protocols were blinded to the patient groups. PROMs in flexion, abduction, and internal and external rotation were measured preinjection, and 2 weeks and 3 months postinjection. None of these patients received other treatments, including physical therapy and another injection at other hospitals during the study period. VOL. 00, NO. 00, MONTH 2014
We compared the improvement of the pain and the change of PROMs postinjection between the LC and GH groups, by Wilcoxon rank sum, and repeated measures analysis of variance (RM-ANOVA) tests with post-hoc analysis for each parameter. Bonferroni correction was adopted using the corrected p values multiplied by the number of statistical analyses to prevent a false positive result caused by multiple statistical analyses. The primary statistical analysis was based on the intention-to-treat principle using the improvement of the pain 3 months postinjection as the primary endpoint. The missing data were managed using the lastobservation-carried-forward technique. Necessary sample size was 42 in each group, based on our preliminary results in which the difference of average improvement scale between 2 groups was 0.3 when type 1 and 2 errors were assumed to be 0.05 and 0.1, respectively. All statistical analyses were done with SPSS 20.0 software (IBM, Armonk, NY, USA). We explained the purpose and procedures of this study to all patients who participated and obtained informed oral consent. We conformed to the ethical guidelines of the 1975 Declaration of Helsinki and the study was approved by our Institutional Review Board.
RESULTS
A total of 675 patients visited our department for shoulder pain during the study period and 192 patients were diagnosed as having adhesive capsulitis. Among them, 92 patients met the criteria of our study and all of them consented to participate. Forty-six patients were allocated to the LC group and the rest to the GH group (Figure 1). The ratio of male-to-female was 24–22 (52.2%) in the LC group and 18–28 (39.1%) in the GH group, which did not show any significant difference (p 5 0.30). The average age of the patients in the LC group (55.5612.4, mean 6 SD) was not significantly different from that in the GH group (56.16 7.8, mean 6 SD) (p 5 0.76). Initial NRS did not show any significant difference between the groups (p 5 0.55). There was no significant difference in baseline PROM between the LC and GH groups. In initial sonographic findings, four patients in the LC group and five patients in the GH group showed supraspinatus tendinosis, which was not significantly different (p 5 1.00). Baseline characteristics of patients were presented in Table 1. 3
KIM ET AL
We compared the findings of physical examination at the initial visit (ie, Neer test, Kennedy-Hawkins test, and bear-hug test). Twenty-eight patients in the LC group and 21 patients in the GH group showed positive Neer test, which was not significantly different between groups (p 5 0.21). Kennedy-Hawkins test results did not reveal any significant difference between the groups (p 5 0.40). Bear-hug test was positive in three patients in the LC group and in two patients in the GH group. Two weeks after the injection, 37 patients expressed “much improved” and 7 patients expressed “slightly improved” pain levels in the
FIGURE 1. Flow diagram of patient recruitment was based on CONSORT (Consolidated Standards of Reporting Trials). Ninety-two patients met the criteria of our study and all of them consented to participate in the study.
LC group, while 18 and 18 patients expressed “much improved” and “slightly improved” pain levels, respectively, in the GH group, which was significantly different (Wilcoxon rank sum p < 0.01). This difference was maintained 3 months postinjection (Wilcoxon rank sum p < 0.01). One patient in the LC group and three patients in the GH group were lost to follow-up. PROMs in all directions improved significantly 3 months postinjection in both the LC and the GH groups; all the p values in each group were 0.001 by RM-ANOVA test. However, there was no significant difference between groups by RM-ANOVA tests (p 5 0.19 in flexion, p 5 0.22 in abduction, p 5 0.97 in internal rotation, and p 5 0.31 in external rotation). The changes of PROM are presented in Figure 2. Among 46 patients in the LC group, 23 patients received the steroid injection into the GH and 23 patients into the subacromial bursa. Initial PROMs in flexion and abduction were not significantly different between two subgroups of different injection sites (p 5 0.95 and 0.35), but the internal and external rotations in the GH injection subgroup were significantly less than those in the subacromial injection subgroup (p 5 0.01 and p < 0.01) (Figure 3). After the injection, the changes of PROM in flexion and abduction were not significantly different between injection sites within the LC group (p 5 0.98 in flexion and 0.71 in abduction). However, there were subgroup differences between injection sites in the changes of internal and
TABLE 1 Baseline Characteristics of Randomly Allocated Patients with Adhesive Capsulitis GH Group LC Group Age, years Gender, male: female NRS score Physical tests: positive number (% in total) Neer test Hawkins test Bear-hug test Range of motion Flexion Abduction Internal rotation External rotation Sonographic findings: positive number (% in total) Supraspinatus tendinosis Calcification
GH Injection (n 5 23)
SA Injection (n 5 23)
Total (n 5 46)
GH Injection (n 5 46)
58.8 6 13.0 12:11 6.4 6 1.3
52.1 6 10.9 12:11 6.3 6 1.2
55.5 6 12.4 24:22 6.3 6 1.2
56.1 6 7.8 18:28 6.2 6 1.2
13 (56.5) 9 (39.1) 0 (0.0)
15 (65.2) 13 (56.5) 3 (13.0)
28 (60.9) 22 (47.8) 3 (6.5)
21 (45.7) 17 (37.0) 2 (4.3)
93.9 6 25.5 66.1 6 33.9 41.3 6 19.1 42.2 6 18.1
93.5 6 17.2 73.9 6 20.4 58.0 6 22.8 61.3 6 17.3
93.7 6 21.5 70.0 6 28.0 49.7 6 22.5 51.7 6 20.0
86.2 6 25.6 66.0 6 17.4 47.8 6 16.5 48.9 6 18.3
2 (8.7) 2 (8.7)
2 (8.7) 0 (0.0)
4 (8.7) 2 (4.3)
5 (10.9) 8 (17.4)
Abbreviations: GH, glenohumeral joint; LC, lidocaine injection test; SA, subacromial bursa.
4
JOURNAL OF CLINICAL ULTRASOUND
LIDOCAINE TEST IN ADHESIVE CAPSULITIS
FIGURE 2. Passive shoulder ranges of motion were increased 3 months postinjection for both the GH and the LC groups. Lower bars are 1 SD of ranges of motion in the GH group and upper bars in the LC group.
FIGURE 3. Passive shoulder ranges of motion were presented for GH and subacromial bursa injection subgroups in the LC group. Lower bars are 1 SD of ranges of motion in GH injection subgroup and upper bars in subacromial bursa injection subgroup. VOL. 00, NO. 00, MONTH 2014
5
KIM ET AL
external rotations (p < 0.01 in internal rotation and p < 0.01 in external rotation). The level of pain reduction was not significantly different between two subgroups of different injection sites within the LC group (Wilcoxon rank sum p 5 0.29 and 0.69 in 2 weeks and 3 months postinjection).
DISCUSSION
We found that a therapeutic steroid injection after determining the injection site (GH or subacromial bursa) with a LC was more effective in reducing pain caused by adhesive capsulitis compared with a standard steroid injection into the GH. The treatment, however, did not affect the level of improvement in terms of range of motion of the shoulder. Lidocaine test injections have been previously used for diagnostic purposes. The LC was used to assist in the diagnosis of full-thickness tear of the supraspinatus tendon13,14 or to exclude GH involvement.15 It has also been used in other parts of the body as well. In the spine, it is often used to determine whether back pain originates from the facet joint before therapeutic steroid injection16 and has been described to determine the source of hip pain from articular or extra-articular pathology.17 Similarly, we believe that this study provided evidence that a LC could increase the success rates of steroid injection in the management of pain from adhesive capsulitis. It may also be useful in preventing multiple, ineffective GH steroid injections with potential side effects, such as hyperglycemia, tendon atrophy, tendon rupture, or osteomyelitis.10 We arbitrarily set the criteria for determining the injection site and classifying the improvement of pain postinjection as a 50% reduction of pain. The rationale was based on the results of a previous study18 in which the criteria used to determine the pain source through the bupivacaine injection were 50% pain reduction. Oh et al7 also used 50% reduction of visual analog scale scores postinjection compared with the initial scores as the criteria of clinical improvement. For the improvement of pain, we used three ordinal scales of pain relief on verbal response, instead of change of NRS. Because adhesive capsulitis is not single dimensional in nature but multidimensional, including discomfort caused by the limitation of motion, it makes the subjective feeling more clinically meaningful 6
than a single number.19 However, to estimate the pain reduction and functional improvement postinjection more accurately, additional scales including SPADI (Shoulder Pain and Disability Index) and ASES (American Shoulder and Elbow Surgeons) score will be necessary. In a preliminary study (data not shown), we found that patients who did not show improvement after the subacromial bursa lidocaine injection showed the improvement after the GH lidocaine injection. Therefore, we did not believe that 2 ml of lidocaine solution injected into the subacromial bursa would affect the pain from GH origin, even though dispersal rates for subacromial bursa and GH injections range from 16 to 19%.20 In the current study, we did not attempt lidocaine injection at the GH in patients who did not show the pain improvement after the subacromial bursa lidocaine injection, because our goal was to reduce the number of injections. Future studies to find the pain source other than the subacromial bursa and GH will supplement our current understanding. We found that lidocaine injection at subacromial bursa was responsive in 50% of patients with adhesive capsulitis (23 of 46 patients in the LC group). This suggested that the pain source of adhesive capsulitis might be emanating from the subacromial bursa. We excluded the patients who had evidence of subacromial bursa swelling or wall-thickening on sonographic imaging study with positive signs of Neer and Hawkins tests. We found that of four patients with supraspinatus tendinopathy, two patients were responsive to subacromial bursa lidocaine injection, while two patients were unresponsive. Therefore, it is likely that concordant subacromial pathology might not affect the responsiveness of subacromial bursa lidocaine injection. To date, there is no clear explanation why steroid injection into the subacromial bursa would be effective in reducing pain caused by adhesive capsulitis. Although the subacromial bursa is separated from the GH by the superior aspect of the rotator cuff, it is possible that the inflammatory mediators can spread from the GH to the subacromial bursa or vice versa through the rotator cuff interval. Alternatively, inflammation may occur widely from the GH to the subacromial space through the supraspinatus muscle or tendon. Because the rotator interval was reportedly involved in a proliferative inflammatory process in adhesive capsulitis,21 this explanation may be plausible. Furthermore, JOURNAL OF CLINICAL ULTRASOUND
LIDOCAINE TEST IN ADHESIVE CAPSULITIS
a recent MRI study22 revealed that thickening of the coracohumeral ligament and joint capsule at the rotator interval were the most characteristic findings in patients with adhesive capsulitis. Our results are also consistent with those from a previous study by Andrieu et al,23 in which subacromial bursography with steroid injection was useful in adhesive capsulitis cases that failed to respond to GH injection. In another study, Oh et al7 revealed that subacromial injection had the same effect as GH injection in adhesive capsulitis, which is also consistent with our findings. Considering that only 24% of patients with adhesive capsulitis showed improvement in pain level after the steroid injection at the GH in a previous study,24 it is likely that the improvement ratio would have increased further, if the injection site were to have been changed to the subacromial space, in unresponsive cases. Patients who received GH injection had more decreased baseline internal and external rotations than those who received subacromial bursa injection in the LC group. This means that patients with adhesive capsulitis with the GH rather than the subacromial space as pain source had more limited internal and external rotation. This was explained by the fact that the problems arising from the GH cause the limitation of all the movement directions, while those arising from the subacromial space limit mainly the flexion and abduction of the shoulder,25,26 rather than the internal and external rotation. In our study, PROM of the shoulder increased at 3 months postinjection in both groups. This could be attributed to self-stretching and strengthening exercises of the shoulder girdle muscles, in addition to the steroid injection.27 Our result of no difference in final PROM between the two groups was possibly due to the same exercise protocols used in both groups. However, we did not investigate the compliance of this self-exercise, which could have biased the range of motion. There are several limitations to our study. Although the patients were randomized, it was not possible to blind the patients to the treatment group because we could not do a LC injection equally in both groups. We were concerned about the ethical implications of a sham LC injection for patients in the GH group. We made an effort to minimize the number of injections (maximum of two) to prevent possible side effects, such as infection, bleeding, and postinjection pain, which made the blinding of VOL. 00, NO. 00, MONTH 2014
patients impossible. This had the potential to bias our results as participants in the LC group who received two-staged injections might have felt that they received more attention (or care) than those who received one injection. Despite the limitations to our study, we believe our findings remain valuable because they suggest the possibility of improving the therapeutic efficacy of steroid injection in adhesive capsulitis. However, future double-blind studies will be necessary to confirm these findings. Another limitation to our study is the possibility that the subacromial test injection within the LC group was more effective as there was a higher number of patients in that subgroup, with shoulder impingement on their physical examination (determined by positive Neer and Hawkins test). It is possible that these patients represented a subgroup of patients who had potentially combined impingement characteristics with adhesive capsulitis. This might explain why the subacromial lidocaine injection together with therapeutic steroid injection provided better relief of pain. Ultrasound ruled out any pathologic changes in the subacromial space and thus minimized inclusion of any true impingement patients in this study, but it is possible that patients with mild or “subclinical” shoulder impingement pain may have been undiagnosed on ultrasound. The last limitation was that, although not statistically significant, there were a higher number of men in the LC group (n 5 22) than in the GH group (n 5 16) despite randomization. A previous study28 revealed that women showed better results of a stretching-exercise program than men; hence, this gender difference might have impacted our results. This may require consideration in future studies with this technique. We found that the use of subacromial bursa LC injection to determine the placement of a therapeutic steroid injection resulted in better improvement of pain than conventional GH injection for patients with adhesive capsulitis. In conjunction with a sound physical therapy regimen, this technique may provide for better outcomes in patients with adhesive capsulitis. Further trials in the form of a double-blind study may be warranted to confirm these findings. REFERENCES 1. Zuckerman JD, Rokito A. Frozen shoulder: a consensus definition. J Shoulder Elbow Surg 2011;20: 322.
7
KIM ET AL 2. Hsu JE, Anakwenze OA, Warrender WJ, et al. Current review of adhesive capsulitis. J Shoulder Elbow Surg 2011;20:502. 3. Neviaser AS, Neviaser RJ. Adhesive capsulitis of the shoulder. J Am Acad Orthop Surg 2011;19:536. 4. Alqunaee M, Galvin R, Fahey T. Diagnostic accuracy of clinical tests for subacromial impingement syndrome: a systematic review and meta-analysis. Arch Phys Med Rehabil 2012;93:229. 5. Girish G, Lobo LG, Jacobson JA, et al. Ultrasound of the shoulder: asymptomatic findings in men. AJR Am J Roentgenol 2011;197:W713. 6. Shin SJ, Lee SY. Efficacies of corticosteroid injection at different sites of the shoulder for the treatment of adhesive capsulitis. J Shoulder Elbow Surg 2013;22:521. 7. Oh JH, Oh CH, Choi JA, et al. Comparison of glenohumeral and subacromial steroid injection in primary frozen shoulder: a prospective, randomized short-term comparison study. J Shoulder Elbow Surg 2011;20:1034. 8. Hall LC, Middlebrook EE, Dickerson CR. Analysis of the influence of rotator cuff impingements on upper limb kinematics in an elderly population during activities of daily living. Clin Biomech (Bristol, Avon) 2011;26:579. 9. Almekinders LC. Impingement syndrome. Clin Sports Med 2001;20:491. 10. Brinks A, Koes BW, Volkers AC, et al. Adverse effects of extra-articular corticosteroid injections: a systematic review. BMC Musculoskelet Disord 2010;11:206. 11. Zwar RB, Read JW, Noakes JB. Sonographically guided glenohumeral joint injection. AJR Am J Roentgenol 2004;183:48. 12. Salaffi F, Stancati A, Silvestri CA, et al. Minimal clinically important changes in chronic musculoskeletal pain intensity measured on a numerical rating scale. Eur J Pain 2004;8:283. 13. Bak K, Sorensen AK, Jorgensen U, et al. The value of clinical tests in acute full-thickness tears of the supraspinatus tendon: does a subacromial lidocaine injection help in the clinical diagnosis? A prospective study. Arthroscopy 2010;26:734. 14. Park JY, Lee WS, Lee ST. The strength of the rotator cuff before and after subacromial injection of lidocaine. J Shoulder Elbow Surg 2008;17(Suppl 1):8S. 15. Anderson BC. Evaluation of the patient with shoulder complaints. UpToDate. [updated 2014 Feb 24; cited 2013 Feb 10]. Available from: http://
8
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
www.uptodate.com/contents/evaluation-of-the-patientwith-shoulder-complaints. Schwarzer AC, Derby R, Aprill CN, et al. The value of the provocation response in lumbar zygapophyseal joint injections. Clin J Pain 1994;10:309. Kivlan BR, Martin RL, Sekiya JK. Response to diagnostic injection in patients with femoroacetabular impingement, labral tears, chondral lesions, and extra-articular pathology. Arthroscopy 2011; 27:619. Schwarzer AC, Aprill CN, Derby R, et al. Clinical features of patients with pain stemming from the lumbar zygapophysial joints. Is the lumbar facet syndrome a clinical entity? Spine 1994;19:1132. Sloman R, Wruble AW, Rosen G, et al. Determination of clinically meaningful levels of pain reduction in patients experiencing acute postoperative pain. Pain Manag Nurs 2006;7:153. Hanchard N, Shanahan D, Howe T, et al. Accuracy and dispersal of subacromial and glenohumeral injections in cadavers. J Rheumatol 2006;33:1143. Petchprapa CN, Beltran LS, Jazrawi LM, et al. The rotator interval: a review of anatomy, function, and normal and abnormal MRI appearance. AJR Am J Roentgenol 2010;195:567. Zhao W, Zheng X, Liu Y, et al. An MRI study of symptomatic adhesive capsulitis. PLoS One 2012; 7:e47277. Andrieu V, Dromer C, Fourcade D, et al. Adhesive capsulitis of the shoulder: therapeutic contribution of subacromial bursography. Rev Rhum Engl Ed 1998;65:771. Bal A, Eksioglu E, Gulec B, et al. Effectiveness of corticosteroid injection in adhesive capsulitis. Clin Rehabil 2008;22:503. Michener LA, McClure PW, Karduna AR. Anatomical and biomechanical mechanisms of subacromial impingement syndrome. Clin Biomech (Bristol, Avon) 2003;18:369. Hinterwimmer S, Von Eisenhart-Rothe R, Siebert M, et al. Influence of adducting and abducting muscle forces on the subacromial space width. Med Sci Sports Exerc 2003;35:2055. De Carli A, Vadala A, Perugia D, et al. Shoulder adhesive capsulitis: manipulation and arthroscopic arthrolysis or intra-articular steroid injections? Int Orthop 2012;36:101. Griggs SM, Ahn A, Green A. Idiopathic adhesive capsulitis. A prospective functional outcome study of nonoperative treatment. J Bone Joint Surg Am 2000;82:1398.
JOURNAL OF CLINICAL ULTRASOUND
