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NSAIDs may be better than steroids for SIS

By Peter Pollack

NSAIDs result in greater improvements in motion, pain

Pressure on the rotator cuff from the shoulder blade as the arm is lifted often results in subacromial impingement syndrome (SIS), a common shoulder injury among overhead athletes. Symptoms include pain and swelling in the shoulder, and the syndrome is usually treated nonsurgically.

Fig. 1 Patients received a subacromial injection, using the standard posterolateral approach; patients were randomized to receive either a corticosteroid or an NSAID injection. (Reproduced from Buss DD, Freehill MQ, Marra G: Typical and Atypical Shoulder Impingement Syndrome: Diagnosis, Treatment, and Pitfalls. Instr Course Lect. 2009;58:447-457)

“Subacromial corticosteroid injections are widely used to treat SIS, but have been associated with tendon rupture, subcutaneous fat atrophy, and articular cartilage changes,” explained Kyong Su Min, MD, of Madigan Army Medical Center, Fort Lewis, Wash., at the 2011 annual meeting of the American Orthopaedic Society for Sports Medicine (AOSSM). “This study, demonstrates that, at 4-weeks follow-up, SIS patients who received an injection with a nonsteroidal anti-inflammatory drug (NSAID) showed statistically and clinically significant improvements compared to those who received corticosteroids.”

The double-blinded study of 48 patients diagnosed with SIS randomized patients to receive either a corticosteroid or NSAID injection (24 patients in each group). All syringes contained 6 mL of 1 percent lidocaine with epinephrine to which 40 mg of triamcinolone (corticosteroid group) or 60 mg of ketorolac (NSAID group) had been added. The patients were recruited from the Orthopaedic Sports Medicine clinic at Madigan Army Medical Center.

“To ensure a double-blind evaluation,” said Dr. Min, “the pharmacy prepared unlabeled, unidentified syringes. The contents of the syringes were kept in a sealed envelope, and neither the evaluator nor the patient nor the injector knew the contents of the syringe. Each patient received an injection in the subacromial bursa, using the standard posterolateral approach (Fig. 1). A reduction of pain after injection confirmed the placement.”

Overall, 32 patients completed the study: 17 in the NSAID group and 15 in the corticosteroid group.

A sustained response
“Prior to treatment, patients in the NSAID group were able to actively abduct an average of 129 degrees, while patients in the corticosteroid group had an average 137 degrees of abduction,” he said. “Immediately following injection, both groups had increased abduction. At the 4-week follow-up, abduction in the NSAID group increased to 151 degrees, but fell in the corticosteroid group, to 134 degrees. This was a statistically significant result.

“Both groups had a good immediate response, but only the NSAID group had a sustained response,” he continued.

Although at baseline both groups averaged 17 points on the University of California, Los Angeles Shoulder Assessment Score (UCLA SAS), the mean improvement at 4 weeks was higher for patients in the NSAID group (7.15) than in the corticosteroid group (2.13). In addition, subgroup analysis of the UCLA SAS showed that forward flexion strength increased in patients in the NSAID group, but decreased in those in the corticosteroid group. Patients in the NSAID group also expressed greater patient short-term satisfaction with their treatment than patients in the corticosteroid group.

“Our study suggests that, at 4 weeks follow-up, NSAID injections have better efficacy than corticosteroids,” said Dr. Min. “Local NSAID injections have not resulted in any reports of tissue atrophy or cartilaginous damage, which is a clinically important and pertinent advantage of using them.

“Although both corticosteroid and NSAID injections are effective in the treatment of isolated subacromial impingement, NSAID injections appear to have a better local anti-inflammatory effect and do not expose the patient to the potential side-effects of corticosteroids. We believe this treatment option requires further research and evaluation,” he concluded.

Dr. Min’s coauthors of “A Double-Blind Randomized Controlled Trial Comparing the Effects of Subacromial Injection with Corticosteroid versus Non-Steroidal Anti-Inflammatory Drugs in Patients with Shoulder Impingement Syndrome” included Patrick St. Pierre, MD; Paul Ryan, MD; Bryant G. Marchant, MD; Christopher J. Wilson, MD; and Edward D. Arrington, MD.

Disclosure information: Drs. Min, Marchant, Arrington, Ryan, and Wilson—no conflicts; Dr. St. Pierre—no information available.

Peter Pollack is a staff writer for AAOS Now. He can be reached at ppollack@aaos.org

Bottom Line

  • This small double-blinded randomized controlled trial compared the use of NSAID injections to corticosteroid injections for treatment of SIS.
  • Although all SIS patients showed immediate improvement, only those who received the NSAID injection continued to show improvement at 4 weeks.
  • Because NSAID injections are not associated with tissue atrophy or damage to cartilage, they may be a viable alternative in the treatment of SIS.

AAOS Now
October 2011 Issue
http://www.aaos.org/news/aaosnow/oct11/clinical1.asp