title: Intra-articular Steroid Injection for Frozen Shoulder: A Systematic Review and Meta-analysis of Randomized Controlled Trials With Trial Sequential Analysis.
abstract: BACKGROUND
  Intra-articular steroid injection is a common intervention for frozen shoulder (FS).
  
  
  OBJECTIVE
  This review aimed to illustrate the effects of intra-articular steroid injection for FS.
  
  
  METHODS
  Systematic review and meta-analysis.
  
  
  METHODS
  PubMed, Embase, and the Cochrane Library were searched for randomized controlled trials (RCTs) comparing intra-articular steroid injection with no injection or sham injections for FS. Visual analog scale (VAS) pain scores were the primary outcome measure. Secondary outcome measures included passive external rotation, abduction, flexion, internal rotation, and functional scores. Complication rates were the safety outcome measure. Comparisons were performed with mean differences (MDs) and 95% confidence intervals (95% CIs). Three time intervals were analyzed: 4 to 6 weeks, 12 to 16 weeks, and 24 to 26 weeks postintervention. Trial sequential analysis was used to verify the pooled results. Line charts were drawn to view the recovery trend in both the intervention and control groups.
  
  
  RESULTS
  Eight RCTs with 416 patients were included. Compared with controls, patients who received intra-articular steroid injection had significantly reduced VAS pain scores at 4 to 6 weeks (MD, 1.28 cm [95% CI, 0.75 to 1.82]), 12 to 16 weeks (MD, 1.00 cm [95% CI, 0.47 to 1.52]), and 24 to 26 weeks (MD, 0.65 cm [95% CI, 0.19 to 1.10]) postinjection. Trial sequential analysis confirmed the pooled results at 4 to 6 weeks and 12 to 16 weeks but not at 24 to 26 weeks. Patients who received intra-articular steroid injection had improved passive external rotation, abduction, and flexion and Shoulder Pain and Disability Index (SPADI) scores at all 3 time intervals, as well as improved American Shoulder and Elbow Surgeons (ASES) scores at 12 to 16 weeks (MD, 12.20 [95% CI, 2.55 to 21.85]). No difference was noticed in Constant scores (MD, 5.70 [95% CI, -0.59 to 11.99]) or internal rotation except at 12 to 16 weeks (MD, 0.81° [95% CI, 0.18° to 1.44°]) and 24 to 26 weeks (MD, 3.88° [95% CI, 0.51° to 7.25°]) between steroid injection and placebo. Complication rates were 1.78% for facial flushing, 0.71% for dizziness owing to vasovagal reactions during injection, 1.07% for chest or shoulder pain, and 0.36% for nausea. Line charts improved in both groups.
  
  
  CONCLUSIONS
  Intra-articular steroid injection is effective and safe for FS and relieves pain, improves functional performance, and increases range of motion. The effects are significant at 4 to 6 and 12 to 16 weeks postintervention and may last as long as 24 to 26 weeks.
authors.affiliation: Department of Sports Medicine, Huashan Hospital, Shanghai, China.
authors.forename: Yaying
authors.initials: Y
authors.lastname: Sun
authors.affiliation: Department of Orthopedics, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China.
authors.forename: Peng
authors.initials: P
authors.lastname: Zhang
authors.affiliation: Department of Sports Medicine, Huashan Hospital, Shanghai, China.
authors.forename: Shaohua
authors.initials: S
authors.lastname: Liu
authors.affiliation: Department of Sports Medicine, Huashan Hospital, Shanghai, China.
authors.forename: Hong
authors.initials: H
authors.lastname: Li
authors.affiliation: Department of Sports Medicine, Huashan Hospital, Shanghai, China.
authors.forename: Jia
authors.initials: J
authors.lastname: Jiang
authors.affiliation: Department of Sports Medicine, Huashan Hospital, Shanghai, China.
authors.forename: Shiyi
authors.initials: S
authors.lastname: Chen
authors.affiliation: Department of Sports Medicine, Huashan Hospital, Shanghai, China.
authors.forename: Jiwu
authors.initials: J
authors.lastname: Chen
mesh_terms: D002062:Bursitis / Q000188:drug therapy* / Q000503:physiopathology; D006801:Humans; D007270:Injections, Intra-Articular; D017063:Outcome Assessment, Health Care; D016032:Randomized Controlled Trials as Topic; D020069:Shoulder Pain / Q000188:drug therapy / Q000503:physiopathology; D013256:Steroids / Q000008:administration & dosage*
chemical_list: D013256:Steroids
keywords: frozen shoulder; randomized clinical trials; review; steroid injection; systematic