Ann Rehabil Med.  2011 Oct;35(5):664-672. 10.5535/arm.2011.35.5.664.

Subacromial Bursa Injection of Hyaluronate with Steroid in Patients with Peri-articular Shoulder Disorders

• Byun SD
• Park DH
• Choi WD
• Lee ZI

• KMID: 2267228
• DOI: http://doi.org/10.5535/arm.2011.35.5.664

Abstract

OBJECTIVE
To investigate the additive effect of sono-guided subacromial bursa injection of hyaluronate with steroid in patients with peri-articular shoulder disorders. METHOD: This prospective randomized controlled trial involved 26 patients who had shoulder pain. Group A, consisting of 13 patients, was treated with a sono-guided subacromial bursa injection containing a mixture of 0.5% lidocaine (5 ml) and triamcinolone 40 mg (1 ml), followed by injection with sodium hyaluronate (2 ml) once a week for 3 weeks. The other 13 patients (Group B) were treated with a sono-guided subacromial bursa injection containing a mixture of 0.5% lidocaine (5 ml) and triamcinolone 40 mg (1 ml) once a week for 3 weeks. The effects were assessed using a visual analogue scale (VAS) of shoulder pain, active range of motion (AROM), shoulder function assessment scale (SFA), shoulder disability questionnaire (SDQ) at study entry and every week from first injection until 4 weeks after the 1st injection (= 2 weeks after 3rd injection).
RESULTS
(1) Demographic features and all parameters measured before injection did not show a significant difference between the 2 groups. (2) Statistically significant improvements were shown in VAS, SFA, SDQ during the 1st, 2nd, and 4th week after the first injection in both groups (p<0.05). (3) SFA showed significant improvement at 1 week after injection only in group A (p<0.05). (4) AROM of internal rotation showed significant improvement at week 4 after the 1st injection only in group A (p<0.05).
CONCLUSION
Subacromial bursa injection of hyaluronate with steroid in patients with peri-articular shoulder disorders has additive effects on functional improvement of the affected shoulder, including the AROM of internal rotation.

Keyword

Sodium hyaluronate; Bursa injection; Peri-articular shoulder disorder; Steroid

MeSH Terms

Humans
Hyaluronic Acid
Lidocaine
Prospective Studies
Range of Motion, Articular
Shoulder
Shoulder Pain
Triamcinolone
Surveys and Questionnaires
Hyaluronic Acid
Lidocaine
Triamcinolone

Figure

• 

  Fig. 1 Figure shows ultrasound guided subacromial/subdeltoid bursa injection. The needle tip is positioned at subacromial/subdeltoid bursa (A). Subacromial/subdeltoid bursa is dilatated due to the injection materials (B).

• 

  Fig. 2 Figure shows the changes of visual analogue scale (VAS) after 3 consecutive injections. *p<0.05 pre-injection vs 2 weeks after 3rd injection. †p<0.05 pre-injection vs 1 week after 1st injection. ‡p<0.05 1 week after 1st injection vs 1 week after 2nd injection. §p<0.05 1 week after 2nd injection vs 2 weeks after 3rd injection.

• 

  Fig. 3 Figure shows the changes of shoulder function assessment scale (SFA) after 3 consecutive injections. *p<0.05 pre-injection vs 2 weeks after 3rd injection. †p<0.05 preinjection vs 1 week after 1st injection. ‡p<0.05 1 week after 1st injection vs 1 week after 2nd injection. §p<0.05 1 week after 2nd injection vs 2 week after 3rd injection.

• 

  Fig. 4 Figure shows the changes of shoulder disability questionnaire (SDQ) after 3 consecutive injections. *p<0.05 pre-injection vs 2 weeks after 3rd injection. †p<0.05 pre-injection vs 1 week after 1st injection. ‡p<0.05 1 week after 1st injection vs 1 week after 2nd injection. §p<0.05 1 week after 2nd injection vs 2 weeks after 3rd injection.

• 

  Fig. 5 Figure shows the changes of AROM of shoulder flexion after 3 consecutive injections. *p<0.05 pre-injection vs 2 weeks after 3rd injection. †p<0.05 pre-injection vs 1 week after 1st injection. ‡p<0.05 1 week after 1st injection vs 1 week after 2nd injection. §p<0.05 1 week after 2nd injection vs 2 weeks after 3rd injection.

• 

  Fig. 6 Figure shows the changes of AROM of shoulder abduction after 3 consecutive injection. *p<0.05 pre-injection vs 2 weeks after 3rd injection. †p<0.05 pre-injection vs 1 week after 1st injection. ‡p<0.05 1 week after 1st injection vs 1 week after 2nd injection. §p<0.05 1 week after 2nd injection vs 2 weeks after 3rd injection.

• 

  Fig. 7 Figure shows the changes of AROM of shoulder abduction after 3 consecutive injection. *p<0.05 pre-injection vs 2 weeks after 3rd injection. †p<0.05 pre-injection vs 1 week after 1st injection. ‡p<0.05 1 week after 1st injection vs 1 week after 2nd injection. §p<0.05 1 week after 2nd injection vs 2 weeks after 3rd injection.

• 

  Fig. 8 Figure shows the changes of AROM of shoulder external rotation after 3 consecutive injection. *p<0.05 pre-injection vs 2 weeks after 3rd injection. †p<0.05 pre-injection vs 1 week after 1st injection. ‡p<0.05 1 week after 1st injection vs 1 week after 2nd injection. §p<0.05 1 week after 2nd injection vs 2 weeks after 3rd injection.

• 

  Fig. 9 Degree of changes in measurement values (VAS, SFA, SDQ, AROM) of the 2 groups. *p<0.05 steroid vs steroid plus hyaluronate.

Reference

1. Blair B, Rokito AS, Cuomo F, Jarolem K, Zuckerman JD. Efficacy of injections of corticosteroids for subacro mial impingement syndrome. J Bone Joint Surg Am. 1996; 78:1685–1689. PMID: 8934482.

2. Darlington LG, Coomes EN. The effects of local steroid injection for supraspinatus tears. Rheumatol Rehabil. 1977; 16:172–179. PMID: 910094.

3. White RH, Paull DM, Fleming KW. Rotator cuff tendinitis: comparison of subacromial injection of a long acting corticosteroid versus oral indomethacin therapy. J Rheumatol. 1986; 13:608–613. PMID: 3735283.

4. Itokazu M, Matsunaga T. Clinical evaluation of highmolecular-weight sodium hyaluronate for the treatment of patients with periarthritis of the shoulder. Clin Ther. 1995; 17:946–955. PMID: 8595646.

5. Leardini G, Perbellini A, Franceschini M, Mattara L. Intra-articular injections of hyaluronic acid in the treatment of painful shoulder. Clin Ther. 1988; 10:521–526. PMID: 2856594.

6. Cho KH, Song JY, Lee H, Kim JS, Rhee YG. The effect of subacromial bursa injection of hyaluronate in patients with adhesive capsulitis of shoulder joint: multicenter, prospective study. J Korean Acad Rehabil Med. 2002; 26:73–80.

7. Chou WY, Ko JY, Wang FS, Huang CC, Wong T, Wang CJ, Chang HE. Effect of sodium hyaluronate treatment on rotator cuff lesions without complete tears: a randomized, double-blind, placebo controlled study. J Shoulder Elbow Surg. 2010; 19:557–563. PMID: 19963403.

8. Kim C, Ahn JK, Park YB, Park YK, Rue HW, Kim DY. The effect of sono-guided intraarticular injection of hyaluronate in shoulder adhesive capsulitis. J Korean Assoc Pain Med. 2007; 6:82–88.

9. Brue S, Valentin A, Forssblad M, Werner S, Mikkelsen C, Cerulli G. Idiopathic adhesive capsulitis of the shoulder : a review. Knee Surg Sports Traumatol Arthrosc. 2007; 15:1048–1054. PMID: 17333122.

10. van Den Ende CH, Rozing PM, Dijkmans BA, Verhoef JA, Voogt-van der Harst EM, Hazes JM. Assessment of shoulder function in rheumatoid arthritis. J Rheumatol. 1996; 23:2043–2048. PMID: 8970039.

11. Croft P, Pope D, Zonca M, O'Neill T, Silman A. Measure ment of shoulder related disability: results of a validation study. Ann Rheum Dis. 1994; 53:525–528. PMID: 7944638.

12. Cho KH, Gee SJ, Lee HJ, Hwang SH. Comparison of blind technique and ultrasonography guided technique of subacromial subdeltoid bursa injection. J Korean Acad Rehabil Med. 2010; 34:209–213.

13. Tillander B, Franzen LE, Karlsson MH, Norlin R. Effect of steroid injections on the rotator cuff: an experimental study in rats. J Shoulder Elbow Surg. 1999; 8:271–274. PMID: 10389085.

14. Akpinar S, Hersekli MA, Demirors H, Tandogan RN, Kayaselcuk F. Effects of methylprednisolone and betamethasone injections on the rotator cuff : an experimental study in rats. Adv Ther. 2002; 19:194–201. PMID: 12431045.

15. Yoon SH, Kwack KS, Rah UW, Cho KH. Ultrasonography-guided subacromial bursal injection of corticosteroid: a comparative study of two dose regimens. J Korean Acad Rehabil Med. 2009; 33:402–407.

16. Bhatia M, Singh B, Nicolaou N, Ravikumar KJ. Correlation between rotator cuff tears and repeated subacromial steroid injections: a case-controlled study. Ann R Coll Surg Engl. 2009; 91:414–416. PMID: 19409148.

17. Yoshimi T, Kikuchi T, Obara T, Yamaguchi T, Sakakibara Y, Itoh H, Iwata H, Miura T. Effects of high-molecular-weight sodium hyaluronate on experimental osteoarthrosis induced by the resection of rabbit anterior cruciate ligament. Clin Orthop Relat Res. 1994; 298:296–304. PMID: 8118990.

18. Iwata H. Pharmacologic and clinical aspects of intraarticular injection of hyaluronate. Clin Orthop Relat Res. 1993; 289:285–291. PMID: 8472428.

19. Leardini G, Perbellini A, Franceschini M, Mattara L. Intra-articular injections of hyaluronic acid in the treatment of painful shoulder. Clin Ther. 1988; 10:521–526. PMID: 2856594.

20. Rosier RN, Okeefe RJ. Hyaluronic acid therapy. Instr Course Lect. 2000; 49:495–502. PMID: 10829203.

21. Tamai K, Mashitori H, Ohno W, Hamada J, Sakai H, Saotome K. Synovial response to intraarticular injections of hyaluronate in frozen shoulder: a quantitative assessment with dynamic magnetic resonance imaging. J Orthop Sci. 2004; 9:230–234. PMID: 15168175.

22. Noel E, Thomas T, Shaeverbeke T, Thomas P, Bonjean M, Revel M. Frozen shoulder. Joint Bone Spine. 2000; 67:393–400. PMID: 11143905.

23. Kim C, Park Y, Youn JE, Kim DY. Treatment of adhesive capsulitis with steroid injection followed by hyaluronic acid injection. J Korean Acad Rehabil Med. 2010; 34:310–315.