Fig. 1 Immediate post-injection visual analog scale improvement as predictorLOA/MUA, Lysis of Adhesions/Manipulation Under Anesthesia
Courtesy of Brian C. Werner, MD


Published 6/1/2020
Kerri Fitzgerald

Immediate Pain Relief Following Steroid Injection Not Predictive of Need for Future Surgery

Editor’s note: The following content was published in the AAOS Now Special Edition and distributed in June 2020. The content was originally scheduled for the AAOS Now Daily Edition, which publishes each year onsite at the AAOS Annual Meeting but this year’s meeting in March was canceled due to COVID-19. Despite the cancellation, members can access virtual content from the Annual Meeting by visiting the Academy’s Annual Meeting Virtual Experience webpage.

Immediate relief of pain after a fluoroscopic-guided glenohumeral injection for idiopathic adhesive capsulitis of the shoulder is not predictive of eventual need for manipulation under anesthesia (MUA) and/or lysis of adhesions (LOA), according to a study that was presented by Brian C. Werner, MD, an assistant professor of orthopaedic surgery at the University of Virginia Health System, as part of the Annual Meeting Virtual Experience.

“Anecdotally, we felt that patients who had a good immediate anesthetic response to a steroid injection for adhesive capsulitis did better than those who didn’t,” Dr. Werner told AAOS Now. “[But] the study actually disproved our hypothesis. … We were surprised by this finding.”

This single-institution, multisurgeon, retrospective study included 797 patients (mean age, 56 years; 68 percent were female) who underwent fluoroscopic corticosteroid injections for a diagnosis of idiopathic adhesive capsulitis between 2010 and 2017. Evaluable patients were a minimum of one year after injection and had immediate pre- and post-injection visual analog scale (VAS) pain scores. The researchers excluded patients with prior ipsilateral shoulder surgery or a diagnosis of concomitant glenohumeral osteoarthritis.

The main outcome measure was ipsilateral LOA/MUA within one year after injection. Researchers calculated immediate pain reduction after injection by subtracting the post-injection VAS score from the pre-injection score.

In this cohort, 48 patients (6 percent) underwent LOA/MUA and 227 (28 percent) underwent subsequent injection. Patients with diabetes were more likely to require subsequent steroid injections than those without diabetes (P = 0.004).

Immediate change in VAS score following injection was not significantly associated with eventual need for LOA/MUA (P = 0.518) (Fig. 1). In addition, pre-injection VAS (P = 0.201) (Fig. 2, available in the online version) and immediate post-injection VAS (P = 0.887) (Fig. 3, available in the online version) were not significant predictors of eventual LOA/MUA (secondary outcomes).

“For all three predictors, the area under the curve of the receiver operating characteristic analysis ranged from 0.506 [to] 0.550, classifying them as extremely poor discriminators of the outcome of interest,” the authors noted.

“Patients can be counseled that even if their initial response to an injection is poor, they still have an excellent chance of avoiding surgery, as the overall rate of LOA/MUA was quite low,” Dr. Werner concluded.

The study is limited by its retrospective, single-institution design. The authors also could not standardize how much and what type of physical therapy patients received.

Dr. Werner’s coauthors of Poster 775, “Immediate Pain Relief at Time of Corticosteroid Injection is Not Predictive of Eventual Need for Lysis of Adhesions or Manipulation for Idiopathic Adhesive Capsulitis,” are Milos Lesevic; John T. Awowale, MD; Thomas E. Moran, MD; David R. Diduch, MD; and Stephen F. Brockmeier, MD.

Kerri Fitzgerald is the managing editor of AAOS Now. She can be reached at