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Update for Chapter 16: Are corticosteroid injections as effective as
physiotherapy for the treatment of a painful shoulder?

Daniëlle A.W.M. van der Windt, PhD

Senior researcher
Institute for Research in Extramural Medicine (EMGO Institute), and
Department of General Practice
Vrije Universiteit medical centre, Amsterdam, The Netherlands

Bart W. Koes, PhD

Professor of General Practice
Faculty of Medicine and Health Sciences, Department of General Practice
Erasmus University Rotterdam, The Netherlands

Are corticosteroid injections as effective as physiotherapy for the treatment of a painful
shoulder?

Introduction
In this review we systematically summarize the available evidence on the effectiveness of
physiotherapy and corticosteroid injections for shoulder pain. The review is an update of Chapter
16 of Evidence-based Sports Medicine.[1]

Methods
Search strategy
Relevant trial reports were identified in M

EDLINE

, E

MBASE

, and the Cochrane Databases. For the

update of this review the search was extended to include the period January 2001 to October
2003, using the same keywords and selection criteria.

Quality assessment
The internal validity of each trial was scored by two reviewers independently, using the validity
criteria of the Amsterdam-Maastricht Consensus List for Quality Assessment.[2] The number of
positively scored validity items was denoted as the validity score.

Data extraction and analysis
Details on selection criteria, interventions, outcome assessment, adverse reactions, and results
were extracted for each trial. Pooled estimates of outcome were computed for trials that showed
sufficient homogeneity with respect to interventions and outcome measures using a random-
effects model.[3] Data concerning general improvement of symptoms were used to compute
success rates for each study group. The differences in success rates between study groups were
computed, together with the 95% confidence intervals (CI). Subsequently, the number needed to
treat (NNT) was computed. For outcomes evaluated on a continuous or interval scale
standardized mean differences (SMD) were computed.[4]

Results
The updated search resulted in the identification of 154 additional papers. 143 abstracts were
excluded for the following reasons: no randomisation (n=31); irrelevant diagnosis (e.g.
hemiplegic shoulder pain or fracture) (n=74); irrelevant intervention (e.g. anaesthesia during
surgery) (n=21); no contrast for injections or physiotherapy (n=13); data for shoulder pain not
presented separately (n=2); or no full report (n=2). A total of 11 papers were retrieved. Five
RCTs were excluded upon reading the full paper as the comparison turned out to be of no
relevance to the review.[5-9] Finally, six RCTs were added to the review (Table I).[10-15]

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Click here for Table 1

Methodological quality
The median validity score of the newly identified trials was 5.5 points. Three trials were of
relatively good quality.[10-12]. The study sizes were generally small; only one trial compared
study groups of at least 100 patients, and was designed with sufficient power to detect clinically
relevant differences.[11]

Effectiveness of corticosteroid injection compared to “placebo”
A total of 15 trials (including two new RCTs) compared the effectiveness of corticosteroid
injection to a treatment considered to be of little or no effectiveness. In nine trials a significantly
better outcome was reported for corticosteroids. Information about treatment success was
available for 12 trials. There was considerable statistical heterogeneity across trials. As explained
in the previous edition of this review one trial seemed to be an outlier, and was excluded from the
analysis. For the remaining 11 trials the pooled estimate for short-term difference in success rate
was 30% in favour of corticosteroids (95% CI 17 to 44%, NNT = 3). Statistical heterogeneity
could not fully be explained by differences across trials regarding quality of methods, diagnosis,
type of steroid, or duration of symptoms. There was wide variation in the definition of a
treatment success, which may partly explain persisting heterogeneity.

Only four trials presented sufficient data for improvement of pain or functional disability.

The pooled estimates were statistically significant in favour of corticosteroids for both pain
(SMD=0.71, 95% CI: 0.42 to 1.01) and disability (SMD=0.45, 95% CI: 0.07 to 0.83).

Effectiveness of physiotherapy (exercises and mobilisations)
Three newly indentified RCTs compared the effects of physiotherapy with saline injection [10],
no treatment [14] or home exercises [15]. Significant effects on pain and function were found for
a home exercise programme in construction workers with shoulder impingement syndrome.[14].
A quantitative analysis of the total set of seven trials was not possible due to clinical
heterogeneity, and insufficient data presentation. The trials already included in the review
provided some evidence that exercise treatment was more effective than placebo or a waiting list
control. Furthermore, the addition of passive mobilisations seemed to be more effective than
treatment consisting of exercises only.

Effectiveness of corticosteroid injections versus physiotherapy
Three newly identified trials [10,11,13] directly compared the effects of corticosteroid injection
and physiotherapy, adding to the four trials already selected for the review. The results are
inconsistent; three out of seven trials (two of relatively good quality) reported significant
differences in favour of corticosteroid injection. However, one large recently published trial [11]
could not demonstrate significant or relevant differences between the two interventions.
Statistical pooling was precluded by the heterogeneity of results. The differences in outcome may
be explained by variation in characteristics of the study population, content of treatment, and
definition of outcome measures.

Long-term effects
Most trials included only a short-term outcome assessment. Long-term follow-up measurements
(at least six months) were described by two newly identified trials.[10,11] The positive short-
term effects of corticosteroids reported by Carrette et al. did not persist after six months of
follow-up.

Adverse reactions
Two newly identified trials included information about adverse reactions to
corticosteroids.[12,13] Adverse reactions were generally mild, and mainly consisted of some pain
and discomfort following the injection.[12] No adverse reactions were reported for
physiotherapy.

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Conclusions
Our updated search identified six relevant trials which were added to the 23 trials already
included in the review. The evidence on the effectiveness of corticosteroid injections and
physiotherapy for shoulder pain is summarized in Table II. The update confirms the evidence for
positive short-term effects of corticosteroid injections compared to placebo. The pooled estimates
for pain and success rate exceeded predefined thresholds for clinical relevance (SMD = 0.5 and
NNT = 5).

Click here for Table 2

Our previous conclusions regarding the positive effects of corticosteroid injection compared to
physiotherapy are weakened by the recent publication of a large trial in which no significant or
relevant differences were found.
Research into the long-term effects of corticosteroid injections is still limited, but existing
evidence indicates that beneficial effects do not persist after six months, with similar outcomes
regardless of treatment.

References
1

Van der Windt DAWM, Koes BW. Are corticosteroid injections as effective as physiotherapy for
the treatment of a painful shoulder? In: MacAuley D, Best TM [Eds]. Evidence-based Sports
Medicine. London: BMJ Books, 2002: 289-317.

2

Van Tulder MW, Assendelft WJJ, Koes BW, Bouter LM. Methodologic guidelines for systematic
reviews in the Cochrane Collaboration Back Review Group for Spinal Disorders. Spine
1997;22:2323-30.

3

DerSimonian R, Laird N. Meta-analysis in clinical trials. Contr Clin Trials 1986;7:177-88.

4 Cohen J. Statistical power analysis for the behavioral sciences [2nd Ed]. Hills Dale, New Jersey:

Lawrence Erlbaum Associates, 1988.

5 Gam AN, Schydlowski P, Rosssel I, Remvig L, Jensen EM. Treatment of “frozen shoulder with

distension and glucocortcoid compared with glucocorticoid alone. Scand J Rheumatol
1998;27:425-30.

6 Rahme H, Solem-Bertoft E, Westerberg CE, Lundberg E, Sorensen S, Hilding S. The subacromial

impingement syndrome. A study of results of treatment with special emphasis on predictive
factors and pain-generating mechanisms. Scand J Rehabil Med 1998; 30: 253-262.

7 Reid D, Saboe L, Chepeha J. Anterior shoulder instability in athletes: comparison of isokinetic

resistance exercises and an electromyographic biofeedback re-edcation program – a pilot
program. Physiotherpy Canada 1996;48:251-6.

8 Shibata Y, Midorikawa K,Emoto G, Naito M. Clinical evaluation of sodium hyaluronate for the

treatment of patients with rotator cuff tear. Shouder Elbow Surg 2001;10:209-16.

9 White AET, Tuite JD. The accuracy and efficacy of shoulder injections in restrictive capsulitis. J

orthop Rheum 1996;9:37-40.

10 Carette S, Moffet H, Tardif J, Bessette L, Morin F, Fremont P, Bykerk V, Thorne C, Bell M,

Bensen W, Blanchette C. Intraarticular corticosteroids, supervised physiotherapy, or a
combination of the two in the treatment of adhesive capsulitis of the shoulder: a placebo-
controlled trial. Arthritis Rheum 2003;48:829-38.

11 Hay EM, Thomas E, Paterson SM, Dziedzic K, Croft PR. A pragmatic randomised controlled trial

of local corticosteroid injection and physiotherapy for the treatment of new episodes of unilateral
shoulder pain in primary care. Ann Rheum Dis 2003;62:394-9.

12 McInerney JJ, Dias J, Durham S, Evans A. Randomised controlled trial of single, subacromial

injection of methylprednisolone in patients with persistent, post-traumatic impingment of the
shoulder. Emerg Med J 2003;20:218-21.

13 Arslan S, Celiker R. Comparison of the efficacy of local corticosteroid injection and physical

therapy for the treatment of adhesive capsulitis. Rheumatol Int 2001;21:20-3.

14 Ludewig PM, Borstad JD. Effects of a home exercise programme on shoulder pain and functional

status in construction workers. Occup Environ Med 2003;60:841-9.

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15 Werner A, Walther M, Ilg A, Stahlschmidt T, Gohlke F. Self-training versus conventional

physiotherapy in subacromial impingement syndrome [German]. Z Orthop Ihre Grenzgeb
2002;140:375-80.