The Egyptian Rheumatologist xxx (2018) xxx–xxx

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The Egyptian Rheumatologist

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Original Article

Efficacy of ultrasonography-guided intra-articular steroid injection of

the shoulder and excercising in patients with adhesive capsulitis:
Glenohumeral versus subacromial approaches
Soha F. Khallaf, Mervat I. Hussein, Amal M. El-Barbary, Radwa M. El Khouly ⇑
Physical Medicine, Rheumatology and Rehabilitation Department, Faculty of Medicine, Tanta University, Egypt

a r t i c l e i n f o a b s t r a c t

Article history: Aim of the work: To evaluate the efficacy of intra-articular steroid injection of the shoulder joint with
Received 11 January 2018 exercises in the management of patients with adhesive capsulitis and to compare glenohumeral (GH) ver-
Accepted 20 January 2018 sus subacromial subdeltoid (SASD) ultrasound-guided approaches.
Available online xxxx
Patients and methods: Forty patients with adhesive capsulitis were randomly divided into 2 groups
according to injection approach. Patients received ultrasound-guided intra-articular injection methyl-
Keywords: prednisolone acetate (40 mg) and 1 ml 2% lidocaine followed by exercise for 12 weeks. Visual analog
Adhesive capsulitis
scale (VAS) for pain, the shoulder pain and disability index (SPADI) and active range of motion (ROM)
Glenohumeral
Subacromial subdeltoid bursa
were assessed before and 12 weeks post-injection.
Ultrasound-guided injection Results: The mean age of the patients was 47.3 ± 8.7 years with 12 females and 8 males in each group.
After injection, there was a significant improvement of pain (VAS) and SPADI in both groups
(p < 0.001). Before injection, SASD bursitis was present in 18 (45%), GH joint effusion in 14 (35%), rotator
cuff tendinopathy in 6 (15%), bursitis with effusion in 1 (2.5%) and with supraspinatus tendon
calcification in another (2.5%). Both groups significantly equally improved regarding to ROM compared
to before injection. Post-injection, the SPADI significantly improved in the SASD group compared to
GH; with remarkable improvement in the joint extension, internal and external rotation (p < 0.001).
Conclusion: Intrarticular steroid injection of the shoulder joint followed by exercises in patients with
adhesive capsulitis decreases pain, improves function and ROM with a more favorable response by the
GH approach. Ultrasound-guided injection is an accurate, easy and cost-effective approach.
Ó 2018 Publishing services provided by Elsevier B.V. on behalf of Egyptian Society of Rheumatic Diseases.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-
nd/4.0/).

1. Introduction capsulitis of the shoulder include the use of analgesics and non
steroidal anti-inflammatory drugs, intra-articular corticosteroid
Adhesive capsulitis of the shoulder is one of the most common administration and physical therapy [2].
causes of pain and stiffness of shoulder, characterized by inflam- In a previous study, diagnostic ultrasound was found useful in
mation of synovial lining and capsule, with subsequent generalized detecting subclinical synovitis in Egyptian patients [3] found com-
contracture of the glenohumeral joint causing shoulder pain and parable to magnetic resonance imaging in detecting subclinical
gradual loss of both passive and active range of motion (ROM). temporomandibular joint abnormalities [4] or in post treatment
Adhesive capsulitis of the shoulder could be primary (idiopathic) follow up of knee synovial hypertrophy in Egyptian patients with
progressive or secondary to other diseases as diabetes mellitus [1]. osteoarthritis [5].
The clinical diagnosis of adhesive capsulitis of the shoulder is Local corticosteroid injection guided by imaging ensures a cor-
based on patient history and physical examination. Treatment of rect injection into the chosen target and reduces the harmful
adhesive capsulitis of the shoulder aims to relieve pain and restore effects of an injection. Ultrasound-guided local corticosteroid
shoulder motion and function. Conventional therapies for adhesive injections have in recent years become a quick and safe procedure
[6]. Ultrasound-guided injection in different lesions as the carpal
tunnel syndrome [7] and plantar fasciitis [8,9] was also found to
Peer review under responsibility of Egyptian Society of Rheumatic Diseases. maximize the effectiveness and reduce complications than blind
⇑ Corresponding author.
injections.
E-mail address: radwa.elkhouli@med.tanta.edu.eg (R.M. El Khouly).

https://doi.org/10.1016/j.ejr.2018.01.005
1110-1164/Ó 2018 Publishing services provided by Elsevier B.V. on behalf of Egyptian Society of Rheumatic Diseases.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Please cite this article in press as: Khallaf SF et al. Efficacy of ultrasonography-guided intra-articular steroid injection of the shoulder and excercising in
patients with adhesive capsulitis: Glenohumeral versus subacromial approaches. The Egyptian Rheumatologist (2018), https://doi.org/10.1016/j.
ejr.2018.01.005
2 S.F. Khallaf et al. / The Egyptian Rheumatologist xxx (2018) xxx–xxx

Subacromial subdeltoid (SASD) injection is widely used for pain 3. Results

relief and functional improvements in patients with SASD bursa,
periarticular shoulder disorder and is mostly injected by corticos- The mean age of the patients was 47.3 ± 8.7 years (29–65
teroids with lidocaine [10]. Also intra-articular glenohumeral years); 49.6 ± 8.6 years in the GH joint approach group and 45.1
(GH) injections have an important function in the diagnosis and ± 8.4 years in SASD group; 12 (60%) of the patients were females
therapeutic intervention of shoulder disorders [11]. and 8 (40%) males in each group. All patients had primary adhesive
The aim of this study was to evaluate the efficacy of intra- capsulitis and were right handed, 60% patients in the GH group and
articular steroid injection of the shoulder joint with exercises in 50% in the SASD group had left shoulder involvement. The demo-
the management of patients with adhesive capsulitis comparing graphic data of the patients according to the injection approaches
GH versus SASD ultrasound-guided approaches. are presented in Table 1 and a comparison between the approaches
regarding the pain, motion and functional status in Table 2. Figs. 1
2. Patients and methods and 2 illustrate the injection approaches and corresponding
ultrasound-guided images.
This study carried out on 40 patients with adhesive capsulitis of On MSKUS examination of the studied patients before injection,
the shoulder. These patients were selected from the outpatient SASD bursitis was present in 18 (45%), GH joint effusion in 14
(35%), rotator cuff tendinopathy (supraspinatus and subscapularis)
clinic of Physical Medicine, Rheumatology and Rehabilitation
in 6 (15%), bursitis with effusion in 1 (2.5%) and with supraspinatus
Department, Faculty of Medicine, Tanta University Hospitals.
tendon calcification in another (2.5%).
Patients with previous trauma, operation, arthritis and intra-
After injection, there was a significant improvement of pain
articular injection in shoulder within last 6 months, secondary to
(VAS) and SPADI in both groups (p < 0.001). Both groups signifi-
brachial plexopathy or other peripheral nerve injury, hemiplegia
cantly equally improved regarding to ROM (flexion, abduction,
were excluded from the study. The study conforms to the 1995
extension, internal rotation and external rotation) compared to
Helsinki declaration and was approved by the ethical committee
before injection. Post-injection, the SPADI significantly improved
of Tanta University Hospital. All patients gave their informed con-
in the SASD group compared to GH; with remarkable improvement
sent prior to their inclusion.
in the joint extension, internal and external rotation (p < 0.001)
Clinical assessment of the patients was performed by assess-
(Table 2).
ment of pain by Visual Analogue Scale (VAS) [12], and goniometric
assessment of active and passive shoulder joint ROM.
Functional assessment of shoulder by Shoulder Pain and 4. Discussion
Disability Index (SPADI) questionnaire [13], which includes 5
questions for pain and 8 questions for disability. In disability In the current study the age of the patient was relatively high
scale, the patients describes his disability where: 0 = no difficulty (29–65 years) suggesting age as an important risk factor for the
and 10 = so difficult and is calculated as: Total pain score: occurrence of adhesive capsulitis. It has been reported that the
___/50  100 = ___%. Total disability score: ___/80  100 = ___%. incidence of adhesive capsulitis is highest between 40 and 60 years
Total SPADI score: ___/130 points (maximum disability: 13 points; [17,18]. Regarding gender, 12 patients (60%) of the GH and the sub-
no disability = 0). acromial groups were females and 8 (40%) were males. These result
Musculoskeletal ultrasound (MSKUS): Ultrasonography was car- were in agreement with Langford, et al. [18] who found that adhe-
ried out for the shoulder, by using SAMSUNG MEDISON (UGEO sive capsulitis affects females more than males.
H60) using linear, high-frequency probes (7.5–12 MHz) at the All of the patients were right-handed; however, 60% of patients
ultrasound unit of Physical Medicine, Rheumatology and Rehabili- in GH group and 50% of those in the SASD group had left shoulder
tation Department of Tanta University Hospital. US of the shoulder involvement. Berquist et al. [19] found that non-dominant shoulder
was performed by a rheumatologist experienced in musculoskele- involvement is more common in adhesive capsulitis.
tal imaging. The imaging protocol for the shoulder evaluation In this study, by MSKUS it was found that there was bursitis,
followed the standard scans by EULAR Anatomy images by effusion and tendinitis in 45%, 35% and 15% respectively with sig-
Sonoanatomy Group- Barcelona University [14]. nificant improvement in both groups after ultrasound-guided
The enrolled patients were randomly divided into two groups injection. Ultrasound is a safe and accurate technique for diagnosis
according to the injection approach yet maintaining a comparable and guiding aspiration and infiltration that ensures correct place-
ment of the needle and delivery of the drug. Naranjo et al. [20],
gender distribution. All patients were intra-articularly injected
Bruyn et al. [21] and Soh et al. [22] reported that ultrasound
ultrasound-guided with 1 ml methyl-prednisolone acetate (40
image-guided corticosteroid injections potentially offer a signifi-
mg) and 1 ml of 2% lidocaine under strict aseptic condition. Group
cantly greater clinical improvement over blind injections in adults
I: 20 patients treated through the GH joint (posterior) approach;
with shoulder pain and proved the effectiveness of the ultrasound
the joint space was located by ultrasound guidance. The needle
in symptomatic arthritic shoulder to detect any pathological
was introduced 1 cm below and lateral to the spine process and
changes.
advanced into the GH joint space; directed horizontal and little lat-
eral [15]. Group II: 20 patients treated through SASD (lateral)
approach, the subacromial space was located ultrasound guided, Table 1
the needle was introduced 1 cm below the acromion angle and Demographic data of the patients with adhesive capsulitis subgroups according to the
injection approach.
advanced SASD [15]. Both groups were given a stretching and
strengthening exercise program for 12 weeks after injection [16]. Data Adhesive capsulitis patients
Statistical analysis: It was carried out using the statistical pack- GH (n = 20) SASD (n = 20)
age for social sciences (SPSS) software, version17.0 for windows.
Age (years) 49.6 ± 8.6 45.1 ± 8.4
Data of patients were expressed as mean ± standard deviation or Sex (female/male) 12 (60):8 (40) 12 (60):8 (40)
median (minimum–maximum) for continuous variables, and cate- Duration (months) 2:12 1:12
gorical variables were shown as the number of cases and%. Mann Affected shoulder (Rt:Lt) 8 (40):12 (60) 10 (50):10 (50)
Dominant hand (right) 20 (100) 20 (100)
Whitney test was used to compare 2 non-parametric quantitative
variables. p < 0.05 was considered significant. GH: Glenohumeral, SASD: subacromial subdeltoid.
Please cite this article in press as: Khallaf SF et al. Efficacy of ultrasonography-guided intra-articular steroid injection of the shoulder and excercising in
patients with adhesive capsulitis: Glenohumeral versus subacromial approaches. The Egyptian Rheumatologist (2018), https://doi.org/10.1016/j.
ejr.2018.01.005
 S.F. Khallaf et al. / The Egyptian Rheumatologist xxx (2018) xxx–xxx 3

Table 2
Comparison between the glenohumeral and subacromial injection approaches in patients with adhesive capsulitis regarding the pain, motion and functional status.

Parameter mean ± SD US-guided steroid injection of the shoulder adhesive capsulitis

GH joint (n = 20) SASD (n = 20) p
before after before after
VAS 9.6 ± 0.5 0.95 ± 0.7a 9.4 ± 0.6 1.1 ± 0.8a (10.29)(20.66)
ROM (°)
Flexion 84.5 ± 21.1 137.8 ± 17.4a 81 ± 23.2 132.5 ± 23.8a (10.62)(20.43)
Abduction 76.8 ± 21.8 126.3 ± 25.3a 80.8 ± 18.7 130.5 ± 26.7a (10.54)(20.61)
Extension 25.8 ± 10.2 52 ± 5.5a 29.3 ± 6.7 56 ± 5.9a (10.21)(20.03)
Int. rotation 20.8 ± 9.4 45.3 ± 7.9a 29.3 ± 10.2 51.3 ± 8.3a (10.009)(20.02)
Ext. rotation 14.3 ± 8.3 35.3 ± 7.7a 18.5 ± 9.3 46 ± 9.95a (10.14)(2<0.001)
SPADI 92.2 ± 6.2 13.3 ± 5.7a 94.3 ± 4.9 19.1 ± 5.7a (10.25)(20.003)

GH: Glenohumeral, SASD: subacromial subdeltoid, VAS: visual analogue scale; SPADI: Shoulder Pain and Disability Index questionnaire. a: p < 0.001 comparing before and
after injection. 1: p compared between both groups before injection, 2: p compared between both groups after injection. Bold values are significant at p < 0.05.

Fig. 1. Musculoskeletal ultrasound-guided steroid injection by the glenohumeral joint approach of a patient with adhesive capsulitis.

Fig. 2. Musculoskeletal ultrasound-guided steroid injection by the subacromial approach of a patient with adhesive capsulitis.

In the current study, all patients with adhesive capsulitis had significantly improved post-injection. The improvement was
moderate to severe pain as assessed by the VAS in both groups significantly more in the SASD group compared with GH group
before injection which significantly improved in both groups after after injection. Oh et al. [26], Byun et al. [27] and Biradar et al.
injection. Similarly, the pre-injection limited ROM in both groups [28] found that patients with adhesive capsulitis injected by single
significantly improved post injection. Shin et al. [23], Ghorai et al. dose of corticosteroid injection followed by exercises program
[24] and Ranalletta et al. [25] found that patients with adhesive were improved for functional outcome assessed according to the
capsulitis who received ultrasound-guided intra-articular steroid shoulder pain and disability index (SPADI).
injection through GH and SASD approaches along with physical In this study intra articular injection combined with exercise
therapy achieved faster pain relief, improvement in shoulder results in better outcome for patients with adhesive capsulitis.
motion and function in all groups. Similarly, Tallia and Cardone [29] recommended the use of corticos-
In the present work, pre-injection, both groups had severe teroid injection combined with other treatment modalities, includ-
functional limitation and disability as assessed by the SPADI which ing physical therapy. Also Hay et al. [30] hypothesized that the use
Please cite this article in press as: Khallaf SF et al. Efficacy of ultrasonography-guided intra-articular steroid injection of the shoulder and excercising in
patients with adhesive capsulitis: Glenohumeral versus subacromial approaches. The Egyptian Rheumatologist (2018), https://doi.org/10.1016/j.
ejr.2018.01.005
4 S.F. Khallaf et al. / The Egyptian Rheumatologist xxx (2018) xxx–xxx

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Please cite this article in press as: Khallaf SF et al. Efficacy of ultrasonography-guided intra-articular steroid injection of the shoulder and excercising in
patients with adhesive capsulitis: Glenohumeral versus subacromial approaches. The Egyptian Rheumatologist (2018), https://doi.org/10.1016/j.
ejr.2018.01.005