Additive effects of hyaluronidase in intra-articular steroid injection treating initial stage adhesive capsulitis of the shoulder: a randomized controlled trial
Objectives: Adhesive capsulitis (AC) is painful and disabling condition that is associated with a gradual loss of shoulder motion. Intra-articular steroid injection is a common treatment in the initial painful stage of AC, and its use in combination with hyaluronidase may offer increased therapeutic efficacy owing to synergistic effects. We determined the therapeutic efficiency of the co-administration of hyaluronidase in early AC by evaluating symptomatic, anthropometric, and imaging changes.
Methods: This randomized controlled trial performed from May 2017 and March 2019 evaluated 1035 patients. Selected eligible patients (n=30) with primary AC in the initial stage were randomly assigned into 3 groups to receive ultrasound-guided intra-articular injections with 20 mg (group A, n=10) and 40 mg triamcinolone acetonide (group B, n=10) and 20 mg acetonide combined with hyaluronidase (group C, n=10). The outcome measures included the visual analogue scale (VAS), the shoulder disability questionnaire (SDQ), abduction and external rotation range of motion, and intra-sheath fluid (ISF) before treatment and at 2, 4, 8, and 16 weeks after treatment.
Results: A total of 29 subjects completed this study and were successfully injected. There were no significant differences in clinical characteristics between the 3 groups. After the injection, the VAS, SDQ, range of flexion and external rotation, and ISF were improved in all groups compared with pre-injection, regardless of the treatment. For the SDQ and ISF, the improvements were more significant in groups B and C than in group A.
Conclusions: The therapeutic efficacy of combined low-dose corticosteroid and hyaluronidase therapy is superior to that of low-dose corticosteroid and equivalent to that of high-dose corticosteroid in early AC.
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Fig. 1. Ultrasonographic evaluation of the upper part of the bicipital groove of the humerus.
Fig. 2. Ultrasound-guided intra-articular injection.
Table 1. The repeated measures ANOVA results of therapeutic effect with regard to symptomatic (VAS and SDQ), anthropometric (abduction and external rotation), and inflammatory (ISF) changes on imaging in the treatment groups [low-dose steroid (group A), high-dose steroid (group B), and combined low-dose steroid and hyaluronidase (group C)]
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