BMJ 1998;317:1292-1296 ( 7 November )

General Practice

Effectiveness of corticosteroid injections versus physiotherapy for treatment of painful stiff shoulder in primary care: randomised trial

D A W M van der Windt, senior investigator, a B W Koes, associate professor, a W Devillé, assistant professor, b A J P Boeke, senior investigator, c B A de Jong, associate professor, d L M Bouter, professor in epidemiology. a

a Institute for Research in Extramural Medicine, Faculty of Medicine, Vrije Universiteit, Van der Boechorststraat 7, 1081 BT Amsterdam, Netherlands, b Department of Epidemiology and Biostatistics, Faculty of Medicine, Vrije Universiteit, c Department of General Practice, Nursing Home Medicine and Social Medicine, Faculty of Medicine, Vrije Universiteit, d Department of Rehabilitation Medicine, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam

Correspondence to: Dr van der Windt dawm.van_der_windt.emgo{at}med.vu.nl

Objective: To compare the effectiveness of corticosteroid injections with physiotherapy for the treatment of painful stiff shoulder.
Design: Randomised trial.
Setting: 40 general practices.
Subjects: 109 patients consulting general practitioners for shoulder pain were enrolled in the trial.
Interventions: Patients were randomly allocated to 6 weeks of treatment either with corticosteroid injections (53) or physiotherapy (56).
Main outcome measures: Outcome assessments were carried out 3, 7, 13, 26, and 52 weeks after randomisation; some of the assessments were done by an observer blind to treatment allocation. Primary outcome measures were the success of treatment as measured by scores on scales measuring improvement in the main complaint and pain, and improvement in scores on a scale measuring shoulder disability.
Results: At 7 weeks 40 (77%) out of 52 patients treated with injections were considered to be treatment successes compared with 26 (46%) out of 56 treated with physiotherapy (difference between groups 31%, 95% confidence interval 14% to 48%). The difference in improvement favoured those treated with corticosteroids in nearly all outcome measures; these differences were statistically significant. At 26 and 52 weeks differences between the groups were comparatively small. Adverse reactions were generally mild. However, among women receiving treatment with corticosteroids adverse reactions were more troublesome: facial flushing was reported by 9 women and irregular menstrual bleeding by 6, 2 of whom were postmenopausal.
Conclusions: The beneficial effects of corticosteroid injections administered by general practitioners for treatment of painful stiff shoulder are superior to those of physiotherapy. The differences between the intervention groups were mainly the result of the comparatively faster relief of symptoms that occurred in patients treated with injections. Adverse reactions were generally mild but doctors should be aware of the potential side effects of injections of triamcinolone, particularly in women.

Key messages

  • There is little evidence supporting the effectiveness of either corticosteroid injections or physiotherapy in painful stiff shoulder

  • Few studies of the effectiveness of treatments for shoulder pain have been done in a primary care setting even though most patients with shoulder pain are treated there

  • This randomised trial shows that patients treated with corticosteroid injections are significantly more likely to improve on measures of pain and disability than patients treated with physiotherapy

  • The differences between those who received injections and those treated with physiotherapy result mainly from comparatively fast relief of symptoms that occurs after injections

  • Doctors and patients should be aware of mild, but sometimes troublesome, adverse reactions to corticosteroids that may occur




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Louis Deliss
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