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Rapid Responses: Rapid Responses published:
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Impingement symptom relief
- Prasad S Pidikiti (1 February 2009)
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Ultrasound-guided versus systemic steroid injection in shoulder impingement syndrome.
- Karim Ochosi (2 February 2009)
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Ultrasound localisation is still essential
- Simon D Carley, Dr Michael Callaghan PhD, Practioner Physiotherapist in Emergency Medicine (4 February 2009)
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Imaginary disease
- Gabriel Symonds (4 February 2009)
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Rotator Cuff Disease
- Louis I Jones (6 February 2009)
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Rotator cuff disease: other confounding, such as occupation?
- Alexis Descatha (23 February 2009)
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Management of suspected rotator cuff disorders in general practice
- Ramon PG Ottenheijm, Ludo Penning, Dept. of Orthopedic Surgery, Geert Jan Dinant, Professor of General Practice, and Rob de Bie, Professor of Physiotherapy Research (9 March 2009)
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Prasad S Pidikiti, Consultant Orthopaedic Surgeon St Helens & Knowsley Teaching hospitals NHS Trust
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I have read with interest 'Subacromial ultrasound guided or systemic steroid injection for rotator cuff disease: randomised double blind study' by Ekeberg et al. No differences were found in the 2 groups. It is hardly surprising as both groups (local and systemic) recieved ultrasound guided lidocaine injections into subacromial region. By this intervention, I am sure both groups are going to benefit from relief of impingement symptoms. We all know that injections lead to only short term relief of symptoms. Overall, this study, though very well thought out, has not contributed anything new to our knowledge. Competing interests: None declared |
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Karim Ochosi, Associate Professor of Exercise Science & Sports Medicine University of Puget Sound, Tacoma, WA 98416
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I commend colleagues Ekeberg et al. (2009) for their efforts in providing further insight as to the optimal approach for treating rotator cuff injuries with injections. The authors put great care into their experimental design. However, the choice to also inject lidocain in the shoulder of those patients who received systematic treatment via corticosteroid injection in the gluteus is not without criticism. It may achieve the ‘blinding’ for the test subject by partly neutralizing the potential pain caused by corticosteroid injection of the shoulder in the localized injection group, but meanwhile it also introduces new confounders. For example, short-term relief of symptoms in the “systemic group” might be a result of a reduction of muscle spasms and tension caused by local lidocain injection rather than by the systemic corticosteroid injection. The authors conclude that short-duration differences between guided versus systemic steroid injection are not dramatic. We must point out, though, that this conclusion really is based on a subjective pain level and range of motion, and, for example, not on a measured degree of inflammation; it can be argued that one implies the other, such would also be an imprudent speculation. On the other hand, even if short-duration differences are only mildly significant, it does not imply that there may not be more significant long-duration differences in other systemic effects of steroid injection, particularly if injections are several times repeated. In all fairness, looking at this was not a purpose of the study by Ekeberg and colleagues, but nevertheless and interesting further question. I would be interested in further examining this topic, perhaps with some minor modifications to the experimental design and to include a number of other agents, such as notably, systemic injection of Diclofenac and Indomethacine. I would also be very interested to see Bufexamac included in the study. Bufexamac in suspension form intended for either systemic or local injection for treatment of a variety of inflammatory muscle and joint problems, was introduced in the late 1970s (Dieux & Famaey, 1979; Loizzi, 1980; Madjuadi & Dequeker, 1978). Bufexamac had the advantage that it was subjectively very well appreciated and effective when administered intra-laesie, in combination with lidocain or the longer working Bupivacain (Dieux & Famaey, 1979). Various authors largely preferred its use over corticosteroid injections (Mardjuadi & Dequeker, 1978), in particular in athletes, who often wanted a quick return to sports practice, where they would want to engage in often explosive and powerful movements. Even though Mielants and co-authors (1987) found the effect of methylprednisolone acetate on inflammation more dramatic than that of Bufexamac, the absence of the atrophic effect of corticosteroids was a crucial and critical advantage, particularly in athletes. Somehow this substance in its injectable form became never widely known and was only distributed in a few countries. It seems that when in the early 1990’s various cases were reported where the topical form of Bufexamac applied in skin problems, led to contact dermatitis, that the manufacturer preventively also removed the injectable form from the market. To the best of my knowledge, though, no such problems were reported after injections. Looking through the literature, I noticed that the last publications focusing on the clinical use of this substance, date from around 2001, reporting favorable effects for use on muscle and joint inflammatory problems in equine medicine (Suominen, et al., 1999, 2001). References Alvarez CM, Litchfield R, Jackowski D, Griffin S, Kirkley A. A prospective, double-blind, randomized clinical trial comparing subacromial injection of betamethasone and xylocaine to xylocaine alone in chronic rotator cuff tendinosis. Am J Sports Med 2005; 33: 255-62. Dieux F, Famaey JP. [Double-blind comparative study of bufexamac and triamcinalone acetonide give by local injection in abarticular rheumatism or osteoarthritis] [article in French]. Acta Rhumatol 1979; 3 (4): 260-4. Ekeberg OM, Bautz-Holter E., Tveitå EK, Juel NG, Kvalheim S, Brox JI. Subacromial ultrasound-guided or systemic steroid injection for rotator cuff disease: randomised double-blind study. BMJ 2009; 338: a3112-273-6. Loizzi P. [A new non steroid anti-inflammatory agent in therapy of osteoarthrosis] [article in Italian]. Clin Ther 1980; 92 (5): 497-512. Mardjuadi A, Dequeker J. Double-blind trial comparing bufexamac infiltrations with triamcinolone acetonide infiltrations in patients with periarthritis of the shoulder. Curr Med Res Opin 1978; 5 (5): 401-5. Mielants H, Raeman F, Proot F, Veys EM. Intra-articular treatment of inflammatory arthritis: double-blind trial comparing bufexamac with methylprednisolone acetate. Clin Rheumatol 1987; 6 (1): 55-60. Suominen MM., Tulamo RM., Anttila MO, Sankari SM, Király K, Lapveteläinen T, Helminen HJ. Effects of intra-articular injections of bufexamac suspension in healthy horses. Am J Vet Res 2001; 62 (10): 1629-35. Suominen MM., Tulamo RM., Puupponen LM, Sankari SM. Effects of intra- articular injections of bufexamac suspension on amphotericin B-induced aseptic arthritis in horses. Am J Vet Res 1999; 60 (12): 1467-73. Competing interests: None declared |
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Simon D Carley, Professor in Emergency Care Centre for Effective Emergency Care, Manchester Metropolitan University, Dr Michael Callaghan PhD, Practioner Physiotherapist in Emergency Medicine
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We found Ekberg et al's paper on subacriomial injection fascinating. It would seem that the site of injection for corticosteroid plays little part in disease resolution. However, we are concerned that this might lead practitioners to not concern themselves with the correct anatomical placement of the subacromial injection. Our experience in the treatment of patients with subacromial disease, and in particular those with subacromial bursitis and/or calcific tendonitis has shown us that identifying the subacromial space through clinical assessment is extremely unreliable. Ultrasound is essential in these patients for two reasons. Firstly, ultrasound can identify partial or complete tears of the rotator cuff muscles (1). Such tears will not resolve with injection therapy and early referral to a shoulder surgeon is essential. Secondly, ultrasound allows the clinician to inject directly into the area of pathology(2). This is virtually impossible to do using landmark techniques as the subacromial bursa is often only millimeters wide. Any clinician who does not use ultrasound to identify the bursa will surely fail to reach the intended target on the majority of occasions. So, we thank Ekberg et al for their paper. It will certainly force us to question our current practice of injecting corticosteroid into the bursa. However, we urge other clinicians to adopt their practice of using ultrasound to guide and confirm the placement of local anesthetic injections in the subacromial bursa. 1. Al-Shawi A, Badge R, Bunker T. The detection of full thickness rotator cuff tears using ultrasound. J Bone Joint Surg Br. 2008;90:889-892 2. Chen MJL, Lew HL, Tsai WC, Tang SFT, Lee YC, Hsu RCH, Chen CPC. Ultrasound-guided shoulder injections in the treatment of sub-acromial bursitis. Am J Phys Med and Rehab. 2006;85:31-35 Competing interests: None declared |
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Gabriel Symonds, General practitioner Tokyo
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It is not surprising that this study, ‘Subacromial ultrasound guided or systemic steroid injection for rotator cuff disease: randomised double blind study’, showed no difference between these two treatments. The very title shows a lamentable lack of understanding about what the authors thought they were treating and how to treat it. What is ‘rotator cuff disease’? I submit no such disease exists. One might as well talk of ‘shoulder pain disease’ or the long discredited ‘periarthritis’. The examination system described is confused. The diagnostic criteria appear to be: pain on abduction (active or passive or both we are not told), up to 49% reduced glenohumeral motion in one direction only (again, we are not told whether this is active or passive limitation or both), with pain on two resisted movements, and a positive ‘impingement’ sign (by which I presume is meant a painful arc). What is the basis for deciding that this complicated combination of physical signs correlates with ‘rotator cuff disease’? In any case, assuming that such an entity as ‘rotator cuff disease’ does exist, what is the logic of attempting to treat it by placing an injection into the subacromial bursa, a different structure? The rotator cuff consists of the tendons of the supraspinatus, infraspinatus, subscapularis, and teres minor muscles blended with the capsule of the shoulder joint. Having decided that the rotator cuff is at fault, the next step is to work out where the lesion lies within this structure: in the supraspinatus, infraspinatus, or subscapularis tendon. This can be simply achieved by a systematic clinical examination (Cyriax 1982, Ombregt 2003). Treatment can then be given by local steroid infiltration to the affected tissue only, with regularly good results. Probably, what Dr Ekeberg and his colleagues were treating was a mixture of conditions, such as lesions of different parts of the rotator cuff and subacromial bursitis. With such heterogeneous patients one cannot expect meaningful results from a clinical trial. References Cyriax J. Textbook of Orthopaedic Medicine, Baillère Tindall, 1982, pp143-168 Ombregt L, et al. A System of Orthopaedic Medicine, Churchill Livingstone, 2003, pp277-383 Competing interests: None declared |
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Louis I Jones, Retired G.P. Bristol BS41 9JD
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We are all encouraged to use evidence-based treatment but what if one's own extensive evidence contradicts the experts? In the case of shoulder pain I treated all patients (and there were over 3000 in a 30 year period) with a local injection combining steroid and local aneasthetic. This was because it was extremely effective in the vast majority of cases, relieving the pain and restoring function in a few days. Many of these patients (though admittingly not all) had rotator cuff disease. It was never clear how much improvement was due to the steroid and how much was due to the local anaesthetic (the combination worked better than either on their own). One has to question, therefore, the validity of the trial in which both groups were given local anaesthetic and I wonder how much this contibuted? Competing interests: None declared |
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Alexis Descatha, Occupational physician, MD PhD Garches, 92380 (Paris Suburb), France
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The study by Ekeberg et al. was interesting but also raised the lack of potential confounder given in randomized control trial. Even though correct randomization in many cases did not led to adjusting on confounders, it is absolutely necessary to describe them.(1) The baseline characteristics were then compared according to the "systemic" and "local" groups. However, the authors did not include some major important confounders, such as pain intensity and occupational variables (other than sick leave and compensation). A systematic review about shoulder disorders in prognostic cohort studies found that there is strong evidence that high pain intensity predicts a poorer outcome in primary care populations, whereas there is moderate evidence that a long duration of complaints, and high disability score at baseline predict a poorer outcome.(2) Occupational variables were also lacking: sick leave, given in the present study, could be interesting and showed the median was not totally similar in the two groups: it’s true there was no significant difference, but the median was at 8 months out-of-work in the "local" group versus 4 in the systemic group; I wonder if others occupational variables were not then different? In fact, we had recently showed that work could be a factor associated with a poorer outcome.(3) I think some minimal occupational variables (for instance manual work), or indirect (highest academic degree) would had been a great interest for the paper. One special comment was about psychosocial factors at works(including stress, low social support): even though there are some evidence of their role in the clinical courses of shoulder pain,(4,5) it is not clear this association remains for patients with clinical findings of with chronic rotator cuff tendinitis.(6) In conclusion, in order to prevent possible confounders, I would have recommended not to forgot important factors associated with the outcome, such as occupation, even in randomized control trial. 1. Haynes RB, Sackett DL, Guyatt GH, Tugwell P. Clinical Epidemiology. Lippincott Williams and Wilkins, 2006. 2. Kuijpers T, van der Windt DA, van der Heijden GJ, Bouter LM. Systematic review of prognostic cohort studies on shoulder disorders. Pain 2004;109:420-31. 3. Descatha, A., Roquelaure, Y., Chastang, J. F., Evanoff, B., Cyr, D., and Leclerc, A. Work, a prognosis factor of upper extremity musculoskeletal disorders? Occup.Environ.Med. In press.[accepted the 9 Sept 2008] 4. Cassou B, Derriennic F, Monfort C, Norton J, Touranchet A. Chronic neck and shoulder pain, age, and working conditions: longitudinal results from a large random sample in France. Occup.Environ.Med. 2002;59:537-44. 5. Kaergaard A,.Andersen JH. Musculoskeletal disorders of the neck and shoulders in female sewing machine operators: prevalence, incidence, and prognosis. Occup.Environ.Med. 2000;57:528-34. 6. Miranda H, Viikari-Juntura E, Heistaro S, Heliovaara M, Riihimaki H. A population study on differences in the determinants of a specific shoulder disorder versus nonspecific shoulder pain without clinical findings. Am.J.Epidemiol. 2005;161:847-55. Competing interests: None declared |
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Ramon PG Ottenheijm, General Practitioner Dept. of General Practice, Maastricht University, 6200 MD, Maastricht, the Netherlands, Ludo Penning, Dept. of Orthopedic Surgery, Geert Jan Dinant, Professor of General Practice, and Rob de Bie, Professor of Physiotherapy Research
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Ekeberg and colleagues conducted a well designed trial with a clear presentation of the results. They conclude that after six weeks no difference is found in outcomes between local ultrasound guided corticosteroid injection and systemic corticosteroid injections in rotator cuff disorders. As outlined by professor Koes in his editorial, several explanations can be given for this conclusion, which emphasises the need for more research on the management of shoulder pain in general practice. Two ideas for future research topics are addressed by us. The effect of corticosteroid injections (local or systemic) is still unconvincing. This might find its reason in the fact that the exact mechanism of pain in rotator cuff disorders is not known. There are several reasons to be reluctant with corticosteroids. Under the current circumstances, administration is performed without any information about the morphology of the rotator cuff. The high recurrence rate in corticosteroid treated patients might be explained by the rapid improvement in pain, which could lead to increased activity and overtaxing the affected shoulder. Decreased pain does not imply that the quality of the affected structures (tissue repair) and their function is improved. Alternatively, corticosteroid injections might be harmful to the tendon. Several animal, histological, and biomechanical studies have supported the argument that the use of corticosteroids may have deleterious effect on collagen, further tendon degeneration, and even tendon rupture.[1-4] The exact mechanism by which corticosteroids might predispose to tendon rupture is not certain. However, there is some experimental evidence indicating that it inhibits the healing process of tendons.[2] This may lead to further tendon degeneration, tear progression, and failure of tendon suturing. In conclusion, there is enough evidence to be reluctant with subacromial corticosteroid injections. Using these drugs, one should keep in mind that it offers only palliative treatment for a short duration and might negatively affect the tendon quality and surgical outcomes. It might be that any substance locally injected in the subacromial space influences histhopathological changes, inflammatory mediators, free nerve endings, and nociceptive agents in the subacromial bursa. This emphasises the need for more studies on the mechanism of pain in rotator cuff disorders, and on how to intervene. Ekebergs’ trial shows once again that diagnosis in patients with shoulder pain is difficult. In 80% of the cases with shoulder pain in general practice, the rotator cuff is the most affected anatomical structure.[5] Unfortunately, physical examination does not allow to differentiate between affected tendons and to diagnose otherwise the disorders.[5] This can be explained by the anatomical structure of the rotator cuff and capsule. In contrast with the description in most anatomical textbooks, there is structural overlap between the tendon fibres and the capsule.[6] This suggests that no test can selectively challenge any one of the rotator cuff tendons. In current usual care, patients are managed without knowledge about the patho-anatomical origin of the symptoms, whereas this is needed to make more adequate decisions regarding treatment. It is likely that solving this diagnostic shortcoming can improve outcome in patients with shoulder pain. Ultrasound imaging can be very useful for detecting rotator disorders[7-9], and is an accurate method for diagnosing rotator cuff tears.[10] It is a relatively inexpensive diagnostic procedure, which allows real time imaging and dynamic assessment of the shoulder. However, before implementation of ultrasound in the management of shoulder pain in general practice can take place, two important questions have to be answered; What is the diagnostic accuracy of ultrasound for the most common rotator cuff disorders?; And in what stage (acute, subacute or chronic) should ultrasound be performed. References: 1. Alvarez, C.M., et al., A prospective, double-blind, randomized clinical trial comparing subacromial injection of betamethasone and xylocaine to xylocaine alone in chronic rotator cuff tendinosis. Am J Sports Med, 2005. 33(2):255-62. 2. Halpern, A.A., B.G. Horowitz, and D.A. Nagel, Tendon ruptures associated with corticosteroid therapy. West J Med, 1977. 127(5):378-82. 3. Hugate, R., et al., The effects of intratendinous and retrocalcaneal intrabursal injections of corticosteroid on the biomechanical properties of rabbit Achilles tendons. J Bone Joint Surg Am, 2004. 86-A(4):794-801. 4. Kapetanos, G., The effect of the local corticosteroids on the healing and biomechanical properties of the partially injured tendon. Clin Orthop Rel Res, 1982(163): 170-179. 5. Winters, J.C., et al., NHG-Standaard Schouderklachten. Huisarts Wet, 2008. 51(11):555-565.(Guideline for shoulder complaints of the Dutch College of General Practitioners) 6. Clark, J. and D. Nd, Tendons, ligaments, and capsule of the rotator cuff. Gross and microscopic anatomy. J Bone Joint Surg Am, 1992. 74(5):713 -725. 7. Allen, G.M. and D.J. Wilson, Ultrasound of the shoulder. Eur J Ultrasound, 2001. 14(1):3-9. 8. Mack, L.A., et al., US evaluation of the rotator cuff. Radiology, 1985. 157(1):205-9. 9. Middleton, W.D., et al., Ultrasonography of the rotator cuff: technique and normal anatomy. J Ultrasound Med, 1984. 3(12):549-51. 10. Dinnes, J., et al., The effectiveness of diagnostic tests for the assessment of shoulder pain due to soft tissue disorders: a systematic review. Health Technol Assess, 2003. 7(29):iii, 1-166. Competing interests: None declared |
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