The Shoulder

Steroid sensitive arthritis of the schoulder

Treatment results with I. A. injections of triamcinolone acetonide

Purpose and method

A multicenter clinical trial ran in the first half of 1989.

The aim of the study was to get an idea about the distribution of this pathology, along with an assessment of evolution and treatment results.

A total of 54 cases were selected that met the following inclusion criteria:

Spontaneously occurring pain in the C5 dermatome.
Absence of trauma.
Absence of other rheumatic complaints.
Clinical examination of the cervical spine as well as neurological examination of the upper limb are normal.
a capsular pattern is found at the shoulder.

Exclusion:
These patients were excluded who at the same time either had a painful arc or were found to have some influence on pain by the resistance tests.

Once the diagnosis of steroid-sensitive arthritis was confirmed, treatment was initiated with intra-articular injections of 20 mg (2 ml) of triamcinolone acetonide. The 10 mg/ml concentration was always used. The technique of injection was the same with every doctor. They used the posterior approach just below the angle formed by the spina scapulae and the acromion

A series of injections were administered. This was in all cases according according to Dr. Cyriax's schedule of ascending intervals. The purpose of this is to put the synovia under continuous anti-inflammatory influence until complete healing is achieved. If the administration is stopped too early or if the next injection is too late, you will indeed see a flare-up of pain and inflammation.

The following conditions were set as criteria for stopping treatment:

The patient should be able to move his arm freely. This does not necessarily mean that the normal amplitude of motion has been completely regained. However, daily use of the arm should no longer cause any discomfort.
A normal end-feel should also be present on clinical examination.
In addition, the pain should not flare up during the month following the last injection.

The following elements were carefully checked at each contact with the patient:

Anamnesis:

Is there spontaneous pain?
Can the patient lie on the shoulder at night?
How far in the arm is the pain felt? The relationship to the elbow is especially important here.

Research:
- The amplitude of the active elevation and of the passive exorotation.
- The end feeling with the passive exorotation.

Results

Monarticular steroid-sensitive arthritis has no gender preference. It occurs equally in men and women.
The study also shows that there is an age-related relationship. Such arthritis appears to be more likely to manifest itself in old age, with an average around age 58. The youngest patient was 40, the oldest 71
Some literature data indicate a relationship between shoulder arthritis and diabetes. This is certainly not reflected in our study as there was only one patient with diabetes.
More than 90% of cases showed stage 2 or 3 arthritis at study entry. These patients had either spontaneous pain or nocturnal pain or both together. In addition, 35% of patients complained of pain seen distal to the elbow. These three elements are directly related to the strength of the inflammation.
The total number of injections administered per patient was between 4 and 9, with an average of 6. In terms of therapeutic effect, it is striking that the element pain in particular is affected quickly. We can even speak of a spectacular improvement in nocturnal pain.

Already after the first injection, this complaint is reduced by half. After 3 injections, only 10% of the selected patients with nocturnal pain remain. In addition, the amount of pain, if still present at that moment, has decreased in intensity to such an extent that it disturbs the patient only slightly. This is a very important fact as many patients often spend weeks of sleepless nights because of the nocturnal pain.

However, for the patient this progress generally only becomes noticeable after the third injection. At that moment we find a global increase in motion for both the elevation and the external rotation of about 30%.

In the same way, but less quickly, the spontaneous pain also decreases. It also shortens at the same time, i.e. it radiates less far distally. This is because the amount of pain reference is proportional to the intensity of the inflammation.

Movement will also increase, but it will take significantly longer before this becomes clear to the patient. Half of the patients had a limitation of external rotation greater than 30' at the first examination. For a small group, the external rotation had even become completely impossible. The limitation of active elevation is less pronounced: about half had a limitation of less than 15°.

From the first injection, careful clinical examination can already reveal a slight improvement in both movements.

The further evolution of motility could only be followed, for reasons of statistical significance, up to and including the 7th injection. At that point of treatment, it has improved by about 80%. It is therefore logical that with such a minimal residual limitation, most patients experience little hindrance during their activities.

when reaching far or during certain sudden movements some pain can still be provoked. That is why in the majority of cases the therapy can be stopped at this stage.

Partly spontaneously, partly as a result of executed movements, the movement amplitude will increase over time. Most patients make a complete recovery. Where there is a certain limitation, it is usually so minimal that the patient is little hindered by it.

Global review

This study tells us that the vast majority of cases of steroid sensitive arthritis respond quickly and well to triamcinolone injections, at least when the joint is kept under the influence of cortisone for a sufficient period of time. If we take into account the duration of the spontaneous recovery, which is between 1 and 2 years, I believe that we can also be satisfied with the treatment duration, which on average covers about three months. The basic condition for such results remains, of course, how could it be otherwise, the exactness of the diagnosis.

The final result is that 98% of patients no longer have any pain after 8 injections. In terms of pain, only one treatment-resistant patient remained from the entire group of patients.