Therapeutic efficacy of low-dose steroid combined with hyaluronidase in ultrasonography-guided intra-articular injections into the shoulder for adhesive capsulitis

Abstract

Purpose: The purpose of this study was to compare the efficacy of low-dose steroid, highdose steroid, and low-dose steroid combined with hyaluronidase with respect to intra-articular injection therapy for adhesive capsulitis (AC) of the shoulder.

Methods: Thirty patients with primary AC in the initial stage were randomly assigned into three groups to receive ultrasound-guided intra-articular injections with 20 mg of triamcinolone acetonide (group A, n=10), 40 mg of triamcinolone acetonide (group B, n=10) and 20 mg of triamcinolone acetonide combined with hyaluronidase (group C, n=10). The outcome measures included a visual analogue scale (VAS), the Shoulder Disability Questionnaire (SDQ), abduction and external rotation range of motion, and intra-sheath fluid (ISF) before treatment and at 2, 4, 8, and 16 weeks after treatment.

Results: Among the 30 patients, one participant in group B dropped out; therefore, a total of 29 patients completed this study and were successfully injected. After the injection, the VAS, SDQ, range of flexion and external rotation, and ISF improved in all groups compared with the preinjection status, regardless of treatment or time point. In the comparison between groups, the SDQ and ISF showed significantly greater improvements in groups B and C than in group A.

Conclusion: The therapeutic efficacy of combined low-dose corticosteroid and hyaluronidase is superior to that of low-dose corticosteroid and equivalent to that of high-dose corticosteroid in early AC.

Keywords: Adhesive capsulitis; Hyaluronidase; Intra-articular injections; Steroids; Ultrasonography.

Fig. 1.. Ultrasonographic evaluation of the upper part of the bicipital groove of the humerus.

A. Scanning of the right shoulder in the longitudinal plane is shown. B. Identification of the hypoechoic fluid enveloping the normal echotexture of the long head of the biceps tendon (asterisk) along the bicipital groove, which starts from the upper part of the rotator cuff interval (RCI) and does not extend beyond the lower part. The solid line indicates the cut-off point of the most inflated level for the axial scanning of C. C. The hypoechoic fluid around the long head of the biceps tendon (asterisk) between the lesser tuberosity (LT) and the greater tuberosity (GT) of the humerus. Intra-sheath fluid (ISF) was calculated by subtracting the area of the inner circle (dotted line) from that of the outer circle (dashed line).

Fig. 2.. CONSORT (Consolidated Standards of Reporting Trials) diagram of the study flow.

Fig. 3.. Ultrasound-guided intra-articular injection.

A. Scanning of posterior shoulder is shown. B. Injection after preparation is shown. C. Transverse scanning image is shown. D. Needle advanced state is shown. E. Injection streaming, which is visible in the Doppler mode, into the joint space between the bony glenoid (BG) and the humeral head (HH) is shown. F. Gap widening (up-down arrow) between the humeral cartilage and the innermost synovial line of the infraspinatus muscle after injection is shown. IS, infraspinatus.

Fig. 4.. Between-group comparisons.

A, B. Repeated-measures analysis of variance results demonstrate statistically significant differences in the therapeutic effect based on the Shoulder Disability Questionnaire (SDQ) (A) as a symptom score and the intra-sheath fluid (ISF) (B) as an imaging measurement of inflammation according to the treatment groups: low-dose steroid (group A), high-dose steroid (group B), and combined low-dose steroid and hyaluronidase (group C).