Subacromial triamcinolone acetonide, hyaluronic acid and saline injections for shoulder pain an RCT investigating the effectiveness in the first days

Background: Subacromial impingement is a common cause of shoulder complaints in general practice. When the initial treatment with acetaminophen and low dose Non Steroidal Anti Inflammatory Drugs fails, triamcinolone acetonide injections are commonly used. Triamcinolone acetonide injections are effective at four to six weeks. Little is known about the pain relief effect of triamcinolone acetonide injections in the first days after injection and the effect of repeated injection. In this study we investigate the effect of triamcinolone acetonide injections compared to hyaluronic acid and NaCl injections using a pain diary. Methods: 159 Patients recruited for an RCT comparing the effect of subacromial injections of triamcinolone acetonide, hyaluronic acid and sodium chloride (NaCl) were used in this study. They were blinded for their treatment and could receive up to three injections. Primary outcome consisted of the patient perceived pain on a VAS score recorded on a daily basis during 21 days following injection. Secondary outcome consisted of the amount of taken escape medication following injection and adverse effects. Results: All patients received the first injection. 150 patients also received the second and third injections. 97% Of the paper and pencil pain diaries were returned for data analysis. The triamcinolone acetonide group showed the largest decrease in pain on the VAS scores after injection compared to the hyaluronic acid and NaCl group in the first week after injection. The reduction in pain was best achieved after the first injection, the second triamcinolone acetonide injection showed a further reduction in pain. The third triamcinolone acetonide injection only showed a slight improvement in pain reduction. Conclusions: In this study we could show a booster effect in pain reduction after repeated triamcinolone acetonide injection. The triamcinolone acetonide group showed a faster reduction in pain after injection compared to the hyaluronic acid and NaCl group. The effect was best seen after the first and second triamcinolone acetonide injection, it is therefore questionable whether it is necessary to repeat triamcinolone acetonide injections more than two times.