Shoulder
A double-blind randomized controlled trial comparing the effects of subacromial injection with corticosteroid versus NSAID in patients with shoulder impingement syndrome

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Hypothesis

The objective of this study was to compare the efficacy of subacromial injection of triamcinolone compared to injection of ketorolac in the treatment of external shoulder impingement syndrome.

Methods

Thirty-two patients diagnosed with external shoulder impingement syndrome were included in this double-blinded randomized controlled clinical trial. Each patient was randomized into the steroid group or nonsteroidal anti-inflammatory drugs (NSAID) group. The steroid syringe contained 40 mg triamcinolone; and the NSAID syringe contained 60 mg ketorolac. Each patient was evaluated in terms of arc of motion, visual analog scale (VAS) for evaluating pain, and the UCLA (The University of California at Los Angeles) shoulder rating scale.

Results

At 1 month follow-up, both treatment arms resulted in increased range of motion and decreased pain. The steroid group decreased in active abduction while the NSAID group increased (steroid: 134°, NSAID: 151°, P = .03). The mean improvement in the UCLA shoulder rating scale at 4 weeks was 7.15 for the NSAID group and 2.13 for the steroid group (P = .03). Subgroup analysis of the UCLA scale demonstrated an increase in both forward flexion strength (P = .04) and patient satisfaction (P = .03) in the NSAID group. No significant difference could be seen in all other outcome measures.

Conclusion

In this study, an injection of ketorolac resulted in greater improvements in the UCLA shoulder rating scale than an injection of triamcinolone at 4 weeks follow-up. While both triamcinolone and ketorolac are effective in the treatment of isolated subacromial impingement, ketorolac appears to have equivalent if not superior efficacy; all the while decreasing patient exposure to the potential side-effects of corticosteroids.

Section snippets

Materials and methods

Patients were recruited from a sports medicine orthopaedic surgery clinic in a tertiary care medical center. Briefly, the inclusion criteria were shoulder pain with passive and/or active abduction, diagnosis of subacromial bursitis based on tenderness to palpation about the acromion, positive Neer’s sign, positive Hawkin’s sign, and pain exacerbated with the shoulder held in internal rotation (Table I). In addition, all patients had standard radiographs of their affected shoulder to rule out

Results

Forty-eight patients met the inclusion and exclusion criteria (Table I) and were enrolled in the study. Of the 48 patients, 24 patients were randomized to the steroid group and 24 patients to the NSAID group. Ten patients were lost to follow-up (7 steroid, 3 NSAID), 1 patient’s consent expired (steroid), and 5 patients were later determined by magnetic resonance imaging (MRI) to have a rotator cuff tear (1 steroid, 4 NSAID). This left 15 patients in the steroid group (average age 40 years;

Discussion

In this study, we used an injectable NSAID to provide a localized area of anti-inflammatory action. Our study suggests that at 4 weeks, NSAID injection has superior efficacy compared to corticosteroid injections, as measured by improvement in the UCLA shoulder rating scale and forward flexion strength. One possible explanation could be that ketorolac has a longer half-life than triamcinolone (ketorolac T½ = 150 min, triamcinolone T½ = 88 min). With the longer half-life, ketorolac may have

Conclusion

In this study, a single injection of 60 mg of ketorolac resulted in improvements in outcomes great than a single injection of 40 mg triamcinolone for the treatment of subacromial impingement when assessed at four weeks. While both triamcinolone and ketorolac are effective in the treatment of isolated subacromial impingement, ketorolac appears to have equivalent if not superior efficacy all the while decreasing patient exposure to the potential side-effects of corticosteroids. Immediately

Disclaimer

None of the other authors, their immediate families and any research foundation with which they are affiliated received any financial payments or other benefits from any commercial entity related to the subject of this article.

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  • Cited by (0)

    This study was reviewed and approved by the Institutional Review Board at Madigan Army Medical Center (US Department of the Army, Combined Meeting of the Clinical Investigation Committee and the Human Use Committee): Study No: 200125.

    There was no external sources of funding for this investigation. This study was registered in Clinical Trials, a service of the United States National Institute of Health (clinicaltrials.gov), and the registry identifier is NCT01449448.

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