Corticosteroid Injections Give Small and Transient Pain... : Clinical Orthopaedics and Related Research® (original) (raw)
Meta-Analysis
Corticosteroid Injections Give Small and Transient Pain Relief in Rotator Cuff Tendinosis: A Meta-analysis
Mohamadi, Amin MD, MPH1; Chan, Jimmy J. MD1; Claessen, Femke M. A. P. MD1; Ring, David MD, PhD2,a; Chen, Neal C. MD1
1Department of Orthopaedics, Hand and Upper Extremity Service, Massachusetts General Hospital, Boston, MA, USA
2Comprehensive Care, Dell Medical School, The University of Texas at Austin, 78701, Austin, TX, USA
ae-mail; [email protected]
Received April 20, 2016/Accepted July 21, 2016; previously published online July 28, 2016
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Each author certifies that all investigations were conducted in conformity with ethical principles of research and that informed consent for participation in the study was obtained.
The protocol of the study is registered and accessible at the international prospective register of systematic reviews (CRD42015025964).
This work was performed at Massachusetts General Hospital-Harvard Medical School, Boston, MA, USA.
Electronic supplementary material
The online version of this article (doi:10.1007/s11999-016-5002-1) contains supplementary material, which is available to authorized users.
A comment to this article is available at http://dx.doi.org/10.1007/s11999-016-5044-4.
Abstract
Background
The ability of injection of corticosteroids into the subacromial space to relieve pain ascribed to rotator cuff tendinosis is debated. The number of patients who have an injection before one gets relief beyond what a placebo provides is uncertain.
Questions/purposes
We asked: (1) Do corticosteroid injections reduce pain in patients with rotator cuff tendinosis 3 months after injection, and if so, what is the number needed to treat (NNT)? (2) Are multiple injections better than one single injection with respect to pain reduction at 3 months?
Methods
We systematically searched seven electronic databases for randomized controlled trials of corticosteroid injection for rotator cuff tendinosis compared with a placebo injection. Eligible studies had at least 10 adults and used pain intensity as an outcome measure. The Hedges's g as adjusted pooled standardized mean difference (SMD) (which expresses the size of the intervention effect in each study relative to the total variability observed among pooled studies) and NNT were calculated at assessment points less than 1 month, 1-2 months, and 2-3 months. The protocol of this study was registered at the international prospective register of systematic reviews. Eleven studies of 726 patients satisfied our criteria for data pooling. Three studies containing 292 patients used repeat injections. A random effects model was used owing to substantial heterogeneity among studies. The funnel plot indicated the possibility of some missing studies, but Orwin's fail-safe N and Duval and Tweedie's trim and fill suggested that missing studies would not significantly affect the results.
Results
Corticosteroid injection did not reduce pain intensity in adult patients with rotator cuff tendinosis more than a placebo injection at the 3-month assessment. A small transient pain relief occurred at the assessment between 4 and 8 weeks with a SMD of 0.52 (range, 0.27-0.78) (p < 0.001). At least five patients must be treated for one patient's pain to be transiently reduced to no more than mild. Multiple injections were not found to be more effective than a single injection at any time.
Conclusions
Corticosteroid injections provide—at best—minimal transient pain relief in a small number of patients with rotator cuff tendinosis and cannot modify the natural course of the disease. Given the discomfort, cost, and potential to accelerate tendon degeneration associated with corticosteroids, they have limited appeal. Their wide use may be attributable to habit, underappreciation of the placebo effect, incentive to satisfy rather than discuss a patient's drive toward physical intervention, or for remuneration, rather than their utility.
Level of Evidence
Level I, therapeutic study.
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