By Alisdair Stirling
Local steroid injections plus exercise are no more effective than exercise alone in the long term for patients with shoulder pain, a major new primary care-based study reveals.
But injection plus exercise is more effective in the short term and GPs are being advised to add a steroid injection to physiotherapy if early pain relief is a priority.
The trial involving pragmatic, randomised trial in patients aged over 40 with subacromial impingement syndrome compared injection plus exercise and exercise alone. Of a total of 232 participants, 115 received subacromial corticosteroid injection plus exercise and 117 exercise only.
Patients had had shoulder pain for a median of 16 weeks. Results published in the BMJ showed that at week 12 of the treatment, there was no significant difference between the groups in change in total pain and disability index.
But improvement in terms of pain and disability was significantly greater in the injection plus exercise group after the first week and at week six – with no differences by week 24.
Around a third of patients treated with exercise alone do not improve sufficiently within three months and will opt for a steroid injection, the study showed.
The researchers noted that because of the pragmatic nature of the study, patients were not blind to their interventions and there could conceivably have been a placebo effect caused by the injection.
Study leader Professor Philip Conaghan, professor of musculoskeletal medicine at the University of Leeds said previous studies had found no long term difference in outcomes. But they had decided to measure shorter term outcomes too because these could be more relevant to GPs deciding on treatment in clinical practice.
He said: ‘We noted a rapid improvement from the steroid injection at one week and the combined injection and exercise resulted in a significantly greater improvement in pain and functional disability at six weeks.
‘If early pain relief is a priority, adding local steroid injection to a course of physiotherapy would seem to be the best option.’
Dr Louise Warburton, a rheumatology and musculoskeletal medicine GPSI for NHS Telford and Wrekin, said many GPs would not be used to giving subacromial injections but if in doubt should refer on.
‘It’s a much smaller joint space and more difficult to do than a gleno-humoral injection for a frozen shoulder.
‘But this chimes with my own experience. I’ve found an injection does the trick but I always send patients on for physio because it´s usually due to a muscle imbalance that needs addressing.’
Injections for shoulder pain ‘have no long-term benefit’