NSAIDs vs Corticosteroid Injections for Frozen Shoulder

Comparison between NSAID and intra-articular corticosteroid injection in frozen shoulder of diabetic patients; a randomized clinical trial. Dehghan A, Pishgooei N, Salami MA, Zarch SM, Nafisi-Moghadam R, Rahimpour S, Soleimani H, Owlia MB. Exp Clin Endocrinol Diabetes. 2013 Feb;121(2):75-9.

Frozen shoulder or adhesive capsulitis is a relatively common encountered musculo-skeletal disease in which arouses following soft tissue involvement of glenohumeral joint and presents with pain and limitation of shoulder’ active and passive motions. The incidence of frozen shoulder among diabetic patients is about 10-20%, stiffness in such patients is more severe and should be managed actively. Local Glucocorticoid injection, NSAIDs and physiotherapy each can relief the symptoms. The aim of this study was to compare the efficacy of glenohumeral injection of Glucocorticoid with NSAIDs in frozen shoulder of diabetic patients.

The randomized clinical trial study conducted during Feb 2009-Aug 2010 on diabetic patients with frozen shoulder that were referred to rheumatology and endocrinology clinics, Yazd, Iran. Diagnostic criteria of capsulitis were pain of shoulder and range of motion limitation in all directions. The patients were divided into 2 groups, patients of first group received NSAID while the latter group were undergone intra-articular corticosteroid injection. After 1 week, home exercise was done for both group and evaluation of the patients after first visit was done likewise 2nd, 6th, 12th and 24th weeks. All registered data were transformed into SPSS-15 software and analyzed.

Totally 57 patients (19 males (33.3%) and 38 females (66.7%) were included in the analysis. There was no significant difference between sex (P=0.4) and age (P=0.19) of patients. No significant relation was detected between 2 groups after 24 weeks according to range of motion in flexion (P=0.51), abduction (P=0.76), external rotation (0.12) and internal rotation (P=0.91). Also any significant difference in pain score was not detected (P=0.91).

Based on our study, both intra-articular corticosteroid and NSAID are effective in treatment of adhesive capsulitis and there is no significant difference between efficacies of these 2 treatment modalities in diabetic patients.

My comments:

I’ve been seeing an increase in physical therapy referrals for patients with frozen shoulder/ adhesive capsulitis patients as of late so I figured I’d review the literature and see f there is anything worth knowing. A few of the papers I have read thus far look good enough to blog on but at least per the research there appears to be more questions than answers, to a large degree because a lot of the prior research is of poor quality. This paper seemed pretty good though and related particularly to patients with diabetes.

They compared 500 mg of the NSAID Naproxin (AKA Aleve) twice daily for which the duration of treatment was unspecified vs a single intra-articular injection of the corticosteroid (40 mg of triamcinolone). The results were roughly similar with no significant difference between groups however the injection group at 2 weeks had a reasonably substantial lead in ROM increases at 2 weeks with shoulder flexion increasing 53.1 degrees in the injection group compared to 37.7 degrees in the NSAID group, abduction was 50.9 vs 42.5 degrees, and external rotation 10.4 vs 9.3 degrees. Later at the 6, 12 and 24 week follow ups the NSAID group mostly caught up but absolute improvements were still a few degrees behind the injection group. I would have thought the researchers were going to recommend the NSAIDs but they advocated the steroid injection saying the one time injection had less side effects than the prolonged NSAID use, which sounds reasonable. I am a big critic of corticosteroid injections for tendinitis/plantar fasciitis per the the general finding that that the result in short term pain loss but 6-8 weeks later those who had injections being worse off than those who had no treatment at all, and with a substantial increased risk for tendinous tissue rupture. However with frozen shoulder and an intra-articular injection the risk reward profile is significantly different with those getting corticosteroid injections appearing to be ahead of controls early on and maintaining these improvements over time though with controls in other studies generally catching up, or almost catching up at 6 months to a year out.

In my clinical experience patients with frozen shoulder, if in the inflammatory stage often, but not always, don’t do well with aggressive stretch and strengthening, and sometimes not that well with milder exercises. If this is the case I have seen a cortisone injection make an immediate night and day difference improving exercise tolerance so that ROM and strength can be restored in a matter of weeks rather 1-3 years which seems to be the normal course of the condition.

One downside noted in the research (including this one) is that there is little if any differentiation between patients in the inflammatory stage of frozen shoulder (when the shoulder is very painful even at rest and sometimes intolerant to any exercise) and the frozen/thawing stages where the shoulder generally does not hurt at rest and tolerates/benefits from strength and stretch just fine. In the later stages I would not expect either the injections nor the NSAIDs to make much difference, but I think that the drugs do, and the injection does particularly quickly is knock out the inflammation quickly so that the exercises can sooner be effective.

Thanks for reading my blog. If you have any questions or comments (even hostile ones) please don’t hesitate to ask/share. If you’re reading one of my older blogs, perhaps unrelated to neck or back pain, and it helps you, please remember Spinal Flow Yoga for you or someone you know in the future.

Chad Reilly is a Physical Therapist, obtaining his Master’s in Physical Therapy from Northern Arizona University. He graduated Summa Cum Laude with a B.S. Exercise Science also from NAU. He is a Certified Strength and Conditioning Specialist, and holds a USA Weightlifting Club Coach Certification as well as a NASM Personal Training Certificate. Chad completed his Yoga Teacher Training at Sampoorna Yoga in Goa, India.

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