{"id":98272,"date":"2026-09-01T04:15:00","date_gmt":"2026-08-31T22:45:00","guid":{"rendered":"https:\/\/jocr.co.in\/wp\/?p=98272"},"modified":"2026-09-02T18:31:34","modified_gmt":"2026-09-02T13:01:34","slug":"clinical-outcomes-of-clinico-radiologically-predetermined-patient-specific-multi-site-steroid-injection-in-primary-frozen-shoulder-a-prospective-case-series","status":"publish","type":"post","link":"https:\/\/jocr.co.in\/wp\/2026\/09\/clinical-outcomes-of-clinico-radiologically-predetermined-patient-specific-multi-site-steroid-injection-in-primary-frozen-shoulder-a-prospective-case-series\/","title":{"rendered":"Clinical Outcomes of Clinico-radiologically Predetermined Patient Specific Multi-site Steroid Injection in Primary Frozen Shoulder: A Prospective Case Series"},"content":{"rendered":"<script type='text\/javascript' src='https:\/\/d1bxh8uas1mnw7.cloudfront.net\/assets\/embed.js'><\/script><h2>Introduction<\/h2>\n<p>Frozen shoulder (FS), also known as adhesive capsulitis, is a common pathologic condition of the shoulder joint. It is characterized by progressive shoulder pain and restriction of the range of motion (ROM) <sup>[<a href=\"#R1\">1<\/a>]<\/sup>. The Upper Extremity Committee of ISAKOS defined the term \u201cfrozen shoulder\u201d as idiopathic stiff shoulder, that is, without a known cause. Secondary stiff shoulder is a term that should be used to describe shoulder stiffness with a known cause <sup>[<a href=\"#R2\">2<\/a>]<\/sup>. It has been estimated that 2\u20135% of the general population suffer from FS, and the most affected age group is between 40 and 60 years <sup>[<a href=\"#R3\">3<\/a>]<\/sup>. Although considered idiopathic, it has been associated with other medical conditions, especially diabetes and hypothyroidism. Diabetics are considered to be 2\u20134 times more likely to suffer from FS, while the latter\u2019s prevalence rate in pre-diabetics has been found to be 37.5% <sup>[<a href=\"#R4\">4<\/a>,<a href=\"#R5\">5<\/a>]<\/sup>. Based on the description by Neviaser, the course of FS is primarily divided into four phases, namely, the freezing phase spanning over the first 3 months and posing as shoulder pain associated with moderate limitation of ROM, followed by the painful phase lasting from three to nine months characterized by severe pain and further reduction of ROM, leading to the frozen stage in which pain may or may not be present but ROM is significantly reduced and finally ending in the thawing stage (15\u201324 months) during which there is minimal pain and gradual improvement of ROM <sup>[<a href=\"#R6\">6<\/a>]<\/sup>. The mainstay of non-surgical management includes non-steroidal anti-inflammatory drugs, oral steroids, intra-articular steroid injections, hydro-dilatation of capsule and physiotherapy, the latter being used either solely or in combination with the previous modalities <sup>[<a href=\"#R7\">7<\/a>]<\/sup>.<\/p>\n<p>However, this initial concept of FS being a self-limiting disease that progresses from painful to stiff phases and ultimately leading to full recovery was not only questionable but affected decision-making process of clinicians toward therapeutic intervention <sup>[<a href=\"#R8\">8<\/a>]<\/sup>. It is now established that the natural history of FS does indeed entail risks of limited range and suboptimal function of the shoulder. Thus, the potentially unrealistic assumption of complete resolution with thawing may delay treatment <sup>[<a href=\"#R8\">8<\/a>, <a href=\"#R9\">9<\/a>]<\/sup>, various modalities of which have been proven to be beneficial <sup>[<a href=\"#R10\">10<\/a>]<\/sup>.<\/p>\n<p>Our protocol of administering steroids at multiple sites, including the glenohumeral joint, is strongly supported by recent studies which have found this regimen to be unequivocally superior to single intra-articular steroid injections in pain relief, ROM as well as functional outcomes, without compromising on safety <sup>[<a href=\"#R11\">11<\/a>,<a href=\"#R12\">12<\/a>]<\/sup>. The conundrum of whether to opt for physiotherapy, steroid injection, or a combination of both was resolved by Carette et al., whose study demonstrated that while the steroid-only group experienced significant improvement in pain and range, the pain relief was faster in the combination group. They also concluded that physiotherapy alone was of minimal benefit <sup>[<a href=\"#R13\">13<\/a>]<\/sup>. The current study is to determine the efficacy of patient-specific multi-site landmark-based steroid injection in combination with a standardized physiotherapy protocol followed at our center in the management of FS.<\/p>\n<h2>Materials and Methods<\/h2>\n<p>We identified patients in the shoulder clinic presenting with symptoms directing to FS and constructed a prospective case series. Patients were clinically examined by the fellowship-trained shoulder surgeon on their presentation at a single shoulder clinic. A detailed history was taken, followed by clinical examination highlighting identification of areas of tenderness over the subacromial space, subdeltoid space, intra-articular joint space, and over the biceps tendon as well as assessing ROM. All patients then underwent plain radiographs as well as an ultrasound study to rule out secondary causes of shoulder pain and stiffness and to identify co-existing pathologies, which could be a contraindication to steroid injection (e.g. rotator cuff tears). In cases where ultrasound scans suggested findings other than those attributable to FS, magnetic resonance imaging was requested. Consecutive 94 patients satisfying the definition of FS by The Upper Extremity Committee of ISAKOS were enlisted randomly between January 2020 and September 2023 for the study. Diabetics were required to achieve optimal glycemic control (target of fasting blood sugar &lt;110 mg\/dL for at least 7 consecutive days) before receiving the steroid injections. After obtaining informed consent, under sterile precautions, patient-specific multisite steroid injections were performed in a single sitting in the glenohumeral joint and in areas of clinical tenderness as well as in bursae having sonographic evidence of inflammation (<a href=\"#F1\" class=\"jxi-fig-ref\">Fig. 1<\/a> and <a href=\"#F2\" class=\"jxi-fig-ref\">2<\/a>). The steroid injection consisted 8 mg of betamethasone (4 mg\/mL) mixed with 6 mL of plain 2% lignocaine. 5 mL of the solution was injected into the glenohumeral joint by an anterior-based approach, and the rest of the solution was injected into the other areas of tenderness\/inflammation determined as above. Glenohumeral injection was given using the anterior approach, with the site of injection being 1 cm lateral to the coracoid, medial to the humeral head, and angled slightly superior and lateral. Patients with subacromial inflammation were infiltrated inferior to the posterolateral corner of acromion with the direction slightly lateral, toward the anterolateral corner, and the needle was advanced by 2\u20133 cm.<\/p>\n<figure id=\"F1\" class=\"jxi-figure\"><img width=\"564\" height=\"558\" src=\"https:\/\/jocr.co.in\/wp\/wp-content\/uploads\/469FF1-converted.jpg\" class=\"jxi-figure-img\" alt=\"Figure 1: Illustration of surface marking of shoulder for subcoracoid (Sc), intra-articular (Ia) and biceps (Bi) injections and coracoid process (Cp) viewed from anterior.\" decoding=\"async\" loading=\"lazy\" srcset=\"https:\/\/jocr.co.in\/wp\/wp-content\/uploads\/469FF1-converted.jpg 564w, https:\/\/jocr.co.in\/wp\/wp-content\/uploads\/469FF1-converted-300x297.jpg 300w, https:\/\/jocr.co.in\/wp\/wp-content\/uploads\/469FF1-converted-100x100.jpg 100w, https:\/\/jocr.co.in\/wp\/wp-content\/uploads\/469FF1-converted-25x25.jpg 25w\" sizes=\"auto, (max-width: 564px) 100vw, 564px\" \/><figcaption>Figure 1: Illustration of surface marking of shoulder for subcoracoid (Sc), intra-articular (Ia) and biceps (Bi) injections and coracoid process (Cp) viewed from anterior.<\/figcaption><\/figure>\n<figure id=\"F2\" class=\"jxi-figure\"><img width=\"566\" height=\"610\" src=\"https:\/\/jocr.co.in\/wp\/wp-content\/uploads\/469FF2-converted.jpg\" class=\"jxi-figure-img\" alt=\"Figure 2: Illustration of shoulder surface marking of site for subacromial (SA) injection viewed from posterior\" decoding=\"async\" loading=\"lazy\" srcset=\"https:\/\/jocr.co.in\/wp\/wp-content\/uploads\/469FF2-converted.jpg 566w, https:\/\/jocr.co.in\/wp\/wp-content\/uploads\/469FF2-converted-278x300.jpg 278w\" sizes=\"auto, (max-width: 566px) 100vw, 566px\" \/><figcaption>Figure 2: Illustration of shoulder surface marking of site for subacromial (SA) injection viewed from posterior<\/figcaption><\/figure>\n<figure id=\"F3\" class=\"jxi-figure\"><img width=\"564\" height=\"592\" src=\"https:\/\/jocr.co.in\/wp\/wp-content\/uploads\/469FF3-converted.jpg\" class=\"jxi-figure-img\" alt=\"Figure 3: Low load, long duration inferior capsular stretch.\" decoding=\"async\" loading=\"lazy\" srcset=\"https:\/\/jocr.co.in\/wp\/wp-content\/uploads\/469FF3-converted.jpg 564w, https:\/\/jocr.co.in\/wp\/wp-content\/uploads\/469FF3-converted-286x300.jpg 286w, https:\/\/jocr.co.in\/wp\/wp-content\/uploads\/469FF3-converted-25x25.jpg 25w\" sizes=\"auto, (max-width: 564px) 100vw, 564px\" \/><figcaption>Figure 3: Low load, long duration inferior capsular stretch.<\/figcaption><\/figure>\n<figure id=\"F4\" class=\"jxi-figure\"><img width=\"584\" height=\"357\" src=\"https:\/\/jocr.co.in\/wp\/wp-content\/uploads\/469FF4-converted.jpg\" class=\"jxi-figure-img\" alt=\"Figure 4: Coracohumeral ligament stretch.\" decoding=\"async\" loading=\"lazy\" srcset=\"https:\/\/jocr.co.in\/wp\/wp-content\/uploads\/469FF4-converted.jpg 678w, https:\/\/jocr.co.in\/wp\/wp-content\/uploads\/469FF4-converted-300x183.jpg 300w\" sizes=\"auto, (max-width: 584px) 100vw, 584px\" \/><figcaption>Figure 4: Coracohumeral ligament stretch.<\/figcaption><\/figure>\n<figure id=\"F5\" class=\"jxi-figure\"><img width=\"564\" height=\"525\" src=\"https:\/\/jocr.co.in\/wp\/wp-content\/uploads\/469FF5-converted.jpg\" class=\"jxi-figure-img\" alt=\"Figure 5: Inferior capsular stretch.\" decoding=\"async\" loading=\"lazy\" srcset=\"https:\/\/jocr.co.in\/wp\/wp-content\/uploads\/469FF5-converted.jpg 564w, https:\/\/jocr.co.in\/wp\/wp-content\/uploads\/469FF5-converted-300x279.jpg 300w\" sizes=\"auto, (max-width: 564px) 100vw, 564px\" \/><figcaption>Figure 5: Inferior capsular stretch.<\/figcaption><\/figure>\n<figure id=\"F6\" class=\"jxi-figure\"><img width=\"584\" height=\"297\" src=\"https:\/\/jocr.co.in\/wp\/wp-content\/uploads\/469FF6-converted.jpg\" class=\"jxi-figure-img\" alt=\"Figure 6: Proprioceptive neuromuscular facilitation with deep breathing.\" decoding=\"async\" loading=\"lazy\" srcset=\"https:\/\/jocr.co.in\/wp\/wp-content\/uploads\/469FF6-converted.jpg 726w, https:\/\/jocr.co.in\/wp\/wp-content\/uploads\/469FF6-converted-300x152.jpg 300w\" sizes=\"auto, (max-width: 584px) 100vw, 584px\" \/><figcaption>Figure 6: Proprioceptive neuromuscular facilitation with deep breathing.<\/figcaption><\/figure>\n<p>Subcoracoid steroid injection was done by direct palpation of the tip of the coracoid process, followed by infiltration laterally and inferiorly. The biceps tendon, however, was not directly infiltrated, and the injection was given around the tendon by palpation of the lips of the bicipital groove in the anteromedial aspect of the proximal arm corresponding to the area of tenderness.<\/p>\n<p>Following the injection, the shoulder joint was immobilized for 24 h. Patients were re-examined after 48 h to rule out complications like infection and neurovascular deficits, following which physiotherapy was initiated. The physiotherapy protocol that we utilize is a comprehensive, structured, evidence-based amalgamation of recognized techniques summarized in <a href=\"#T1\" class=\"jxi-fig-ref\">Table 1<\/a> <sup>[<a href=\"#R14\">14<\/a>,<a href=\"#R15\">15<\/a>,<a href=\"#R16\">16<\/a>]<\/sup>.<\/p>\n<div class=\"jxi-table-wrap\"  orientation=\"portrait\" id=\"T1\" position=\"float\">\nTable 1<\/p>\n<p>Physiotherapy protocol<\/p>\n<div class=\"table-responsive\">\n<table class='table'  frame=\"hsides\" rules=\"all\" width=\"100%\">\n<thead>\n<tr>\n<th align=\"center\" colspan=\"2\">Physical therapy (Figs. 3,4,5,6)<\/th>\n<\/tr>\n<tr>\n<th align=\"center\">Phases<\/th>\n<th align=\"center\">Physical therapy<\/th>\n<\/tr>\n<\/thead>\n<tbody>\n<tr>\n<td align=\"center\">Phase 1 (3\u201312 days depending on VAS\/Stiffness)<\/td>\n<td align=\"center\">\u2022 Modalities to reduce pain<\/td>\n<\/tr>\n<tr>\n<td align=\"center\"><\/td>\n<td align=\"center\">\u2022 Mobilization with manual traction<\/td>\n<\/tr>\n<tr>\n<td align=\"center\"><\/td>\n<td align=\"center\">\u2022 Maitland Grade 1 and 2 mobilization techniques:<em><\/em> (<em>Joint mobilization in scapular plane, Manual therapy, Ischemic compression, Inferior capsule stretch<\/em>)<\/td>\n<\/tr>\n<tr>\n<td align=\"center\"><\/td>\n<td align=\"center\">\u2022 Pendulum movements with 1 kg<\/td>\n<\/tr>\n<tr>\n<td align=\"center\"><\/td>\n<td align=\"center\">\u2022 For refractory cases &#8211; Proprioceptive neuromuscular facilitation<\/td>\n<\/tr>\n<tr>\n<td align=\"center\">Phase 2 (2\u20133 weeks till VAS reaches 4 or 5)<\/td>\n<td align=\"center\">\u2022 Grade 3\u20134 Maitland technique<\/td>\n<\/tr>\n<tr>\n<td align=\"center\"><\/td>\n<td align=\"center\">\u2022 Switch from manual to myofascial manipulation<\/td>\n<\/tr>\n<tr>\n<td align=\"center\"><\/td>\n<td align=\"center\">\u2022 Isometric strengthening<\/td>\n<\/tr>\n<tr>\n<td align=\"center\"><\/td>\n<td align=\"center\">\u2022 Active assisted ROM<\/td>\n<\/tr>\n<tr>\n<td align=\"center\"><\/td>\n<td align=\"center\">\u2022 Coracohumeral Ligament stretch<\/td>\n<\/tr>\n<tr>\n<td align=\"center\">Phase 3 (3\u20136 weeks)<\/td>\n<td align=\"center\">\u2022 Maitland Grade 4 Mobilization in end range<\/td>\n<\/tr>\n<tr>\n<td align=\"center\"><\/td>\n<td align=\"center\">\u2022 Low load long end range stretch<\/td>\n<\/tr>\n<tr>\n<td align=\"center\"><\/td>\n<td align=\"center\">\u2022 Active ROM<\/td>\n<\/tr>\n<tr>\n<td align=\"center\"><\/td>\n<td align=\"center\">\u2022 Scapular stabilization<\/td>\n<\/tr>\n<tr>\n<td align=\"center\"><\/td>\n<td align=\"center\">\u2022 Neuromuscular reeducation to maintain gain in range<\/td>\n<\/tr>\n<tr>\n<td align=\"center\">Phase 4<\/td>\n<td align=\"center\" rowspan=\"2\">\u2022 Maintenance for 3\u20134 months once or twice weekly home exercises, especially in diabetics<\/td>\n<\/tr>\n<tr>\n<td align=\"center\">(3\u20134 months)<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/div>\n<p><strong>ROM: Range of motion, VAS: Visual Analog Scale<\/strong><\/p>\n<\/div>\n<div class=\"jxi-subsection\">\n<h4>Inclusion criteria<\/h4>\n<p>Patients were aged \u2013 18\u201377 years and satisfying the definition of FS by the Upper Extremity Committee of ISAKOS. Other causes of limitation of ROM were ruled out clinically and confirmed with radiological means.<\/p>\n<\/div>\n<div class=\"jxi-subsection\">\n<h4>Exclusion criteria<\/h4>\n<p>Patients with arthritic changes, calcific deposits, and rotator cuff tears were excluded based on radiological findings. Patients symptomatic in the contralateral shoulder were excluded. Patients with previous shoulder surgery were excluded.<\/p>\n<\/div>\n<div class=\"jxi-subsection\">\n<h4>Outcome measurements<\/h4>\n<p>ROM and the scores (pre-injection and 2, 4, 8, weeks were measured by one clinical researcher who was blinded to the current study, and the ROM measured with a goniometer. The initial evaluation included the recording of a detailed medical history and clinical examination of the shoulder joint (Active and Passive ROM, tenderness in specific bursae around the joint). Pain was determined by a VAS scoring system, and the ASES scoring and SPADI scoring systems were utilised for evaluation of subjective function at each point in the study. Shoulder ROM was measured with the patient seated. Internal rotation at the back was measured by the vertebral level reached with the tip of the thumb.<\/p>\n<\/div>\n<h2>Results<\/h2>\n<p>The sample size consisted of 94 patients diagnosed with primary adhesive capsulitis, and data were collected from February 2020 to September 2023. The study population comprised 36 men (38%) and 58 women (62%), who were at a mean age of 52.6 \u00b1 10.7 years (range 18\u201377 years). The mean duration of symptoms was 5.1 months \u00b1 2.5 months (range 1\u201312 months). 25 (26%) patients reported a history of diabetes mellitus. About 9 (10%) patients reported a history of hypothyroidism. The female population was higher by 70%. We also noted in our study that in 53 cases, the left shoulder was affected while the right shoulder was affected in the remaining 41 cases. Out of the 94 patients, 51 patients had subacromial tenderness (54%), 31 patients had sub-coracoid tenderness (33%), and 29 patients had tenderness around biceps tendon (31%). <a href=\"#T2\" class=\"jxi-fig-ref\">Table 2<\/a> and <a href=\"#G1\" class=\"jxi-fig-ref\">Graph 1<\/a> depict the results of ROM pre-injection and at 2, 4, and 8 weeks post-injection. Similarly, the functional outcomes and VAS scores are shown in <a href=\"#T3\" class=\"jxi-fig-ref\">Table 3<\/a> and <a href=\"#G2\" class=\"jxi-fig-ref\">Graph 2<\/a>. Abduction, forward flexion and external rotation are all displayed in degrees.<\/p>\n<div class=\"jxi-table-wrap\"  orientation=\"portrait\" id=\"T2\" position=\"float\">\nTable 2<\/p>\n<p>Results of ROM at pre-injection and post-injection visits<\/p>\n<div class=\"table-responsive\">\n<table class='table'  frame=\"hsides\" rules=\"all\" width=\"100%\">\n<thead>\n<tr>\n<th align=\"center\">Timeline<\/th>\n<th align=\"center\">Abduction<\/th>\n<th align=\"center\">Forward flexion<\/th>\n<th align=\"center\">External rotation<\/th>\n<th align=\"center\">Internal rotation (compared to opposite normal shoulder)<\/th>\n<\/tr>\n<\/thead>\n<tbody>\n<tr>\n<td align=\"center\">Pre-injection<\/td>\n<td align=\"center\">123.7<\/td>\n<td align=\"center\">123.4<\/td>\n<td align=\"center\">26.4<\/td>\n<td align=\"center\">5.0 levels lower<\/td>\n<\/tr>\n<tr>\n<td align=\"center\">2 weeks<\/td>\n<td align=\"center\">140.5<\/td>\n<td align=\"center\">138.6<\/td>\n<td align=\"center\">36.7<\/td>\n<td align=\"center\">3.9 levels lower<\/td>\n<\/tr>\n<tr>\n<td align=\"center\">4 weeks<\/td>\n<td align=\"center\">152.7<\/td>\n<td align=\"center\">153<\/td>\n<td align=\"center\">43.4<\/td>\n<td align=\"center\">2.4 levels lower<\/td>\n<\/tr>\n<tr>\n<td align=\"center\">8 weeks<\/td>\n<td align=\"center\">167.4<\/td>\n<td align=\"center\">168.6<\/td>\n<td align=\"center\">50.2<\/td>\n<td align=\"center\">1.5 levels lower<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/div>\n<p><strong>ROM: Range of motion<\/strong><\/p>\n<\/div>\n<figure id=\"G1\" class=\"jxi-figure\"><img width=\"584\" height=\"338\" src=\"https:\/\/jocr.co.in\/wp\/wp-content\/uploads\/469FF7-converted.jpg\" class=\"jxi-figure-img\" alt=\"Graph 1: Results of range of motion at pre-injection and post-injection visits.\" decoding=\"async\" loading=\"lazy\" srcset=\"https:\/\/jocr.co.in\/wp\/wp-content\/uploads\/469FF7-converted.jpg 585w, https:\/\/jocr.co.in\/wp\/wp-content\/uploads\/469FF7-converted-300x174.jpg 300w\" sizes=\"auto, (max-width: 584px) 100vw, 584px\" \/><figcaption>Graph 1: Results of range of motion at pre-injection and post-injection visits.<\/figcaption><\/figure>\n<div class=\"jxi-table-wrap\"  orientation=\"portrait\" id=\"T3\" position=\"float\">\nTable 3<\/p>\n<p>Functional outcomes and VAS scores at pre-injection and post-injection visits<\/p>\n<div class=\"table-responsive\">\n<table class='table'  frame=\"hsides\" rules=\"all\" width=\"100%\">\n<thead>\n<tr>\n<th align=\"center\">Timeline<\/th>\n<th align=\"center\">ASES<\/th>\n<th align=\"center\">SPADI<\/th>\n<th align=\"center\">VAS scoring<\/th>\n<\/tr>\n<\/thead>\n<tbody>\n<tr>\n<td align=\"center\">Pre-injection<\/td>\n<td align=\"center\">28.8<\/td>\n<td align=\"center\">86.8<\/td>\n<td align=\"center\">6.7<\/td>\n<\/tr>\n<tr>\n<td align=\"center\">2 weeks<\/td>\n<td align=\"center\">38.5<\/td>\n<td align=\"center\">79.8<\/td>\n<td align=\"center\">3.5<\/td>\n<\/tr>\n<tr>\n<td align=\"center\">4 weeks<\/td>\n<td align=\"center\">76.8<\/td>\n<td align=\"center\">57.7<\/td>\n<td align=\"center\">1.8<\/td>\n<\/tr>\n<tr>\n<td align=\"center\">8 weeks<\/td>\n<td align=\"center\">88.9<\/td>\n<td align=\"center\">25.0<\/td>\n<td align=\"center\">0.7<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/div>\n<p><strong>ASES: American Shoulder and Elbow Scoring system, SPADI: Shoulder Pain and Disability Index, VAS: Visual Analog Scale<\/strong><\/p>\n<\/div>\n<figure id=\"G2\" class=\"jxi-figure\"><img width=\"584\" height=\"346\" src=\"https:\/\/jocr.co.in\/wp\/wp-content\/uploads\/469FF8-converted.jpg\" class=\"jxi-figure-img\" alt=\"Graph 2: Functional outcomes and Visual Analog Scale scores at pre-injection and post-injection visits.\" decoding=\"async\" loading=\"lazy\" srcset=\"https:\/\/jocr.co.in\/wp\/wp-content\/uploads\/469FF8-converted.jpg 588w, https:\/\/jocr.co.in\/wp\/wp-content\/uploads\/469FF8-converted-300x178.jpg 300w\" sizes=\"auto, (max-width: 584px) 100vw, 584px\" \/><figcaption>Graph 2: Functional outcomes and Visual Analog Scale scores at pre-injection and post-injection visits.<\/figcaption><\/figure>\n<div class=\"jxi-subsection\">\n<h4>Statistical analysis<\/h4>\n<p>The differences in ROM, VAS and functional outcomes between pre-injection status and during post-injection visits were assessed using a paired samples test (<a href=\"#T5\" class=\"jxi-fig-ref\">Table 5<\/a>), while the statistical significance of these differences was evaluated by a Wilcoxon signed ranks test (<a href=\"#T6\" class=\"jxi-fig-ref\">Table 6<\/a>).<\/p>\n<div class=\"jxi-table-wrap\"  orientation=\"portrait\" id=\"T4\" position=\"float\">\nTable 4<\/p>\n<p>Comparison of our results with those of Rashid <em>et al<\/em>. <sup>[<a href=\"#R26\">26<\/a>]<\/sup><\/p>\n<div class=\"table-responsive\">\n<table class='table'  frame=\"hsides\" rules=\"all\" width=\"100%\">\n<thead>\n<tr>\n<th align=\"center\" rowspan=\"2\">Scoring and range of motion<\/th>\n<th align=\"center\" colspan=\"3\">Rashid <em>et al<\/em>.<\/th>\n<th align=\"center\" colspan=\"3\">Our study<\/th>\n<\/tr>\n<tr>\n<th align=\"center\">Pre injection<\/th>\n<th align=\"center\">6<sup>th<\/sup> week<\/th>\n<th align=\"center\">3 months<\/th>\n<th align=\"center\">Pre injection<\/th>\n<th align=\"center\">4<sup>th<\/sup> week<\/th>\n<th align=\"center\">8<sup>th<\/sup> week<\/th>\n<\/tr>\n<\/thead>\n<tbody>\n<tr>\n<td align=\"center\">VAS<\/td>\n<td align=\"center\">5.9<\/td>\n<td align=\"center\">2.2<\/td>\n<td align=\"center\">1.1<\/td>\n<td align=\"center\">6.7<\/td>\n<td align=\"center\">1.8<\/td>\n<td align=\"center\">0.7<\/td>\n<\/tr>\n<tr>\n<td align=\"center\">FF<\/td>\n<td align=\"center\">123<\/td>\n<td align=\"center\">156.1<\/td>\n<td align=\"center\">169<\/td>\n<td align=\"center\">123<\/td>\n<td align=\"center\">153<\/td>\n<td align=\"center\">167<\/td>\n<\/tr>\n<tr>\n<td align=\"center\">ER<\/td>\n<td align=\"center\">34<\/td>\n<td align=\"center\">59.2<\/td>\n<td align=\"center\">66<\/td>\n<td align=\"center\">28<\/td>\n<td align=\"center\">43.4<\/td>\n<td align=\"center\">52<\/td>\n<\/tr>\n<tr>\n<td align=\"center\">ABD<\/td>\n<td align=\"center\">80<\/td>\n<td align=\"center\">109.6<\/td>\n<td align=\"center\">134<\/td>\n<td align=\"center\">123<\/td>\n<td align=\"center\">152.7<\/td>\n<td align=\"center\">166<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/div>\n<p><strong>VAS: Visual Analog Scale, FF: Forward flexion, ER: External rotation, ABD: Abduction<\/strong><\/p>\n<\/div>\n<div class=\"jxi-table-wrap\"  orientation=\"portrait\" id=\"T5\" position=\"float\">\nTable 5<\/p>\n<p>Paired samples test<\/p>\n<div class=\"table-responsive\">\n<table class='table'  frame=\"hsides\" rules=\"all\" width=\"100%\">\n<thead>\n<tr>\n<th align=\"center\" rowspan=\"2\">Scoring duration<\/th>\n<th align=\"center\" colspan=\"5\">Paired differences<\/th>\n<\/tr>\n<tr>\n<th align=\"center\">Mean<\/th>\n<th align=\"center\">Standard Deviation<\/th>\n<th align=\"center\" colspan=\"2\">95% Confidence Interval of the Difference<\/th>\n<th align=\"center\">Sig. (2-tailed)<\/th>\n<\/tr>\n<tr>\n<th align=\"center\">Pair 1<\/th>\n<th align=\"center\"><\/th>\n<th align=\"center\"><\/th>\n<th align=\"center\">Lower<\/th>\n<th align=\"center\">Upper<\/th>\n<th align=\"center\"><\/th>\n<\/tr>\n<\/thead>\n<tbody>\n<tr>\n<td align=\"center\">ASES Pre-inj &#8211; 2 weeks<\/td>\n<td align=\"center\">\u22129.66<\/td>\n<td align=\"center\">2.95<\/td>\n<td align=\"center\">\u221210.26<\/td>\n<td align=\"center\">\u22129.06<\/td>\n<td align=\"center\">0<\/td>\n<\/tr>\n<tr>\n<td align=\"center\">Pair 2<\/td>\n<td align=\"center\"><\/td>\n<td align=\"center\"><\/td>\n<td align=\"center\"><\/td>\n<td align=\"center\"><\/td>\n<td align=\"center\"><\/td>\n<\/tr>\n<tr>\n<td align=\"center\">ASES Pre-inj &#8211; 4 weeks<\/td>\n<td align=\"center\">\u221248.04<\/td>\n<td align=\"center\">4.22<\/td>\n<td align=\"center\">\u221248.91<\/td>\n<td align=\"center\">\u221247.18<\/td>\n<td align=\"center\">0<\/td>\n<\/tr>\n<tr>\n<td align=\"center\">Pair 3<\/td>\n<td align=\"center\"><\/td>\n<td align=\"center\"><\/td>\n<td align=\"center\"><\/td>\n<td align=\"center\"><\/td>\n<td align=\"center\"><\/td>\n<\/tr>\n<tr>\n<td align=\"center\">ASES Pre-inj &#8211; 8 weeks<\/td>\n<td align=\"center\">\u221260.09<\/td>\n<td align=\"center\">4.21<\/td>\n<td align=\"center\">\u221260.95<\/td>\n<td align=\"center\">\u221259.22<\/td>\n<td align=\"center\">0<\/td>\n<\/tr>\n<tr>\n<td align=\"center\">Pair 4<\/td>\n<td align=\"center\"><\/td>\n<td align=\"center\"><\/td>\n<td align=\"center\"><\/td>\n<td align=\"center\"><\/td>\n<td align=\"center\"><\/td>\n<\/tr>\n<tr>\n<td align=\"center\">SPADI Pre-inj &#8211; 2 weeks<\/td>\n<td align=\"center\">7.06<\/td>\n<td align=\"center\">11.24<\/td>\n<td align=\"center\">4.76<\/td>\n<td align=\"center\">9.37<\/td>\n<td align=\"center\">0<\/td>\n<\/tr>\n<tr>\n<td align=\"center\">Pair 5<\/td>\n<td align=\"center\"><\/td>\n<td align=\"center\"><\/td>\n<td align=\"center\"><\/td>\n<td align=\"center\"><\/td>\n<td align=\"center\"><\/td>\n<\/tr>\n<tr>\n<td align=\"center\">SPADI Pre-inj &#8211; 4 weeks<\/td>\n<td align=\"center\">29.10<\/td>\n<td align=\"center\">9.3<\/td>\n<td align=\"center\">27.19<\/td>\n<td align=\"center\">31<\/td>\n<td align=\"center\">0<\/td>\n<\/tr>\n<tr>\n<td align=\"center\">Pair 6<\/td>\n<td align=\"center\"><\/td>\n<td align=\"center\"><\/td>\n<td align=\"center\"><\/td>\n<td align=\"center\"><\/td>\n<td align=\"center\"><\/td>\n<\/tr>\n<tr>\n<td align=\"center\">SPADI Pre-inj &#8211; 8 weeks<\/td>\n<td align=\"center\">61.82<\/td>\n<td align=\"center\">11.36<\/td>\n<td align=\"center\">59.49<\/td>\n<td align=\"center\">64.14<\/td>\n<td align=\"center\">0<\/td>\n<\/tr>\n<tr>\n<td align=\"center\">Pair 7<\/td>\n<td align=\"center\"><\/td>\n<td align=\"center\"><\/td>\n<td align=\"center\"><\/td>\n<td align=\"center\"><\/td>\n<td align=\"center\"><\/td>\n<\/tr>\n<tr>\n<td align=\"center\">VAS Pre-inj &#8211; 2 weeks<\/td>\n<td align=\"center\">3.28<\/td>\n<td align=\"center\">1.24<\/td>\n<td align=\"center\">3.02<\/td>\n<td align=\"center\">3.53<\/td>\n<td align=\"center\">0<\/td>\n<\/tr>\n<tr>\n<td align=\"center\">Pair 8<\/td>\n<td align=\"center\"><\/td>\n<td align=\"center\"><\/td>\n<td align=\"center\"><\/td>\n<td align=\"center\"><\/td>\n<td align=\"center\"><\/td>\n<\/tr>\n<tr>\n<td align=\"center\">VAS Pre-inj &#8211; 4 weeks<\/td>\n<td align=\"center\">4.96<\/td>\n<td align=\"center\">1.37<\/td>\n<td align=\"center\">4.68<\/td>\n<td align=\"center\">5.24<\/td>\n<td align=\"center\">0<\/td>\n<\/tr>\n<tr>\n<td align=\"center\">Pair 9<\/td>\n<td align=\"center\"><\/td>\n<td align=\"center\"><\/td>\n<td align=\"center\"><\/td>\n<td align=\"center\"><\/td>\n<td align=\"center\"><\/td>\n<\/tr>\n<tr>\n<td align=\"center\">VAS Pre-inj \u2013 8 weeks<\/td>\n<td align=\"center\">6.02<\/td>\n<td align=\"center\">1.34<\/td>\n<td align=\"center\">5.75<\/td>\n<td align=\"center\">6.3<\/td>\n<td align=\"center\">0<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/div>\n<p><strong>ASES: American Shoulder and Elbow Scoring system, SPADI: Shoulder Pain and Disability Index, VAS: Visual Analog Scale, Inj: Injection<\/strong><\/p>\n<\/div>\n<div class=\"jxi-table-wrap\"  orientation=\"portrait\" id=\"T6\" position=\"float\">\nTable 6<\/p>\n<p>Wilcoxon signed ranks test<\/p>\n<div class=\"table-responsive\">\n<table class='table'  frame=\"hsides\" rules=\"all\" width=\"100%\">\n<thead>\n<tr>\n<th align=\"center\">Scoring duration<\/th>\n<th align=\"center\">ASES Pre-inj &#8211; 2 weeks<\/th>\n<th align=\"center\">ASES Pre-inj &#8211; 4 weeks<\/th>\n<th align=\"center\">ASES Pre-inj \u2013 8 weeks<\/th>\n<th align=\"center\">SPADI Pre-inj \u2013 2 weeks<\/th>\n<th align=\"center\">SPADI Pre-inj \u2013 4 weeks<\/th>\n<th align=\"center\">SPADI Pre-inj \u2013 8 weeks<\/th>\n<th align=\"center\">VAS Pre-inj \u2013 2 weeks<\/th>\n<th align=\"center\">VAS Pre-inj \u2013 4 weeks<\/th>\n<th align=\"center\">K VAS Pre-inj \u2013 8 weeks<\/th>\n<\/tr>\n<\/thead>\n<tbody>\n<tr>\n<td align=\"center\">Z<\/td>\n<td align=\"center\">\u22128.431<sup>a<\/sup><\/td>\n<td align=\"center\">\u22128.427<sup>a<\/sup><\/td>\n<td align=\"center\">\u22128.429<sup>a<\/sup><\/td>\n<td align=\"center\">\u22124.862<sup>b<\/sup><\/td>\n<td align=\"center\">\u22128.421<sup>b<\/sup><\/td>\n<td align=\"center\">\u22128.420<sup>b<\/sup><\/td>\n<td align=\"center\">\u22128.479<sup>b<\/sup><\/td>\n<td align=\"center\">\u22128.478<sup>b<\/sup><\/td>\n<td align=\"center\">\u22128.482<sup>b<\/sup><\/td>\n<\/tr>\n<tr>\n<td align=\"center\">Asymptotic Significances (2-tailed)<\/td>\n<td align=\"center\">0<\/td>\n<td align=\"center\">0<\/td>\n<td align=\"center\">0<\/td>\n<td align=\"center\">0<\/td>\n<td align=\"center\">0<\/td>\n<td align=\"center\">0<\/td>\n<td align=\"center\">0<\/td>\n<td align=\"center\">0<\/td>\n<td align=\"center\">0<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<\/div>\n<p>a<\/p>\n<p><strong>Based on negative ranks.<\/strong><\/p>\n<p>b<\/p>\n<p><strong>Based on positive ranks. ASES: American Shoulder and Elbow Scoring system, SPADI: Shoulder Pain and Disability Index, VAS: Visual Analog Scale, Inj: Injection<\/strong><\/p>\n<\/div>\n<\/div>\n<h2>Discussion<\/h2>\n<p>In the quest of the ideal treatment for FS, different steroids, injection sites, techniques, and frequency of injection have been studied. As reported by the Consensus Survey of Shoulder Specialists, conservative management remains the most popular as the first line of treatment, and 63% of participants agreed that steroids have a beneficial role <sup>[<a href=\"#R1\">1<\/a>]<\/sup>. However, despite the abundance of therapeutic modalities, there remains a paucity of guidelines regarding the treatment ladder in the management of FS. There is no definitive guideline as to when to change from one treatment modality to another. However, it is generally acceptable to wait for 3 months before declaring any conservative treatment ineffective <sup>[<a href=\"#R17\">17<\/a>]<\/sup>.<\/p>\n<p>The choice of betamethasone for our study is supported by its high potency (more than 6 times that of triamcinolone) and long half-life of 8.5 days <sup>[<a href=\"#R18\">18<\/a>, <a href=\"#R19\">19<\/a>]<\/sup>. Furthermore, its solubility reduces its propensity to crystallize, a process which has been incriminated in post-steroid flare reaction <sup>[<a href=\"#R20\">20<\/a>]<\/sup>.<\/p>\n<p>With regards to the injection technique, White et al had demonstrated that 95% (19 out of 20 patients) of anterior-based injections were accurate compared to a mere 50% (10 out of 20 patients) amongst the posterior approach <sup>[<a href=\"#R21\">21<\/a>]<\/sup>. Our decision to opt for the anterior approach is further supported by Deng et al. who reported that a decrease in VAS was consistently better at each follow-up, and the improvements in functional scores and external rotation were faster and more significant when using the anterior approach rather than the posterior approach for intra-articular steroid injection in FS <sup>[<a href=\"#R22\">22<\/a>]<\/sup>.<\/p>\n<p>Another area of variability in practice is the use of ultrasound-guided (US-guided) versus landmark-based steroid injections. While the accuracy of US-guided injections is higher (90% vs. 76.2%), this difference was not found to be statistically significant in a cohort study of 41 patients by Raeissadat et al. Improvements in pain, functional scores and ROM (except for extension), albeit more in the US-guided group, failed to reach statistical significance <sup>[<a href=\"#R23\">23<\/a>]<\/sup>. The lack of significant clinical benefit of US-Guided compared to landmark-based steroid injections was echoed by a Cochrane study, which concluded that there was no advantage in term of pain, function, shoulder ROM or safety in using the former technique <sup>[<a href=\"#R24\">24<\/a>]<\/sup>. Rather more evident was the fact that US-Guided injections would be more costly and time-consuming <sup>[<a href=\"#R23\">23<\/a>]<\/sup>.<\/p>\n<p>We have strived to base our practice on best available evidence and robust scientific reasoning, but the ultimate litmus test remained our results. The mean VAS score decreased from a pre-injection value of 6.7\u20130.7. This improvement was significantly higher than that achieved by Amos et al who treated their patients by US-Guided triamcinolone injections and reported a mean VAS score reduction from 5.6 to 3.0 <sup>[<a href=\"#R25\">25<\/a>]<\/sup>. Interestingly, this reduction occurred over a mean of 2.1 months, whereas our results demonstrate a comparable VAS of 3.5 at a mere 2 weeks and a VAS of 1.8 at 4 weeks only. Rashid et al. <sup>[<a href=\"#R26\">26<\/a>]<\/sup> evaluated the efficacy of a single intra-articular injection of methylprednisolone combined with physiotherapy and physiotherapy alone (<a href=\"#T4\" class=\"jxi-fig-ref\">Table 4<\/a>). The authors concluded that the results were significantly better in the combination group. The mean VAS score in the combination group decreased to 1.1 from 5.9 at 3 months. The VAS score had reached 2.2 by 6 weeks post-injection. The mean SPADI score improved from 62.5 to 33.0 at 6 weeks and 18.9 at 3 months in his patients, compared to 86.8 at pre-injection to 25.0 at 8 weeks in our study. They also reported a mean increase in internal rotation by 7 levels by 6 weeks and 9 levels by 3 months compared to an improvement of 3.5 levels by 8 weeks. An explanation to this discrepancy could be the fact that his patients overall had a more significantly reduced internal rotation that our patients \u2013 the mean internal rotation was S3, whereas the most severely restricted internal rotation was S1 in our study group. Our study betamethasone has high potency, long half-life, and good solubility, which improves external rotation faster with anterior approach steroid injection. These landmark-based multisite steroid injections are not as accurate as US-guided injections.<\/p>\n<h2>Conclusion<\/h2>\n<p>The results of our prospective case series demonstrate that clinico-radiologically predetermined landmark-based multisite steroid infiltration using betamethasone leads to a remarkable reduction in pain as well as significant improvement in ROM and function in the treatment of FS.<\/p>\n<blockquote class=\"jxi-boxed-text\">\n<p><strong>Clinical Message<\/strong><\/p>\n<p>Clinically, landmark-based multisite betamethasone steroid infiltration, guided by clinical and radiological assessment, appears to be an effective, simple, and minimally invasive treatment option for frozen shoulder, providing significant pain relief and improvement in shoulder motion and function.<\/p>\n<\/blockquote>\n<div class=\"jxi-subsection\">\n<h4>Conflict of Interest:<\/h4>\n<p>Nil<\/p>\n<\/div>\n<div class=\"jxi-subsection\">\n<h4>Source of Support:<\/h4>\n<p>Nil<\/p>\n<\/div>\n<div class=\"jxi-subsection\">\n<h4>Consent:<\/h4>\n<p>The authors confirm that informed consent was obtained from the patient for publication of this article<\/p>\n<\/div>\n","protected":false},"excerpt":{"rendered":"<p>Introduction Frozen shoulder (FS), also known as adhesive capsulitis, is a common pathologic condition of the shoulder joint. It is characterized by progressive shoulder pain and restriction of the range of motion (ROM) [1]. The Upper Extremity Committee of ISAKOS defined the term \u201cfrozen shoulder\u201d as idiopathic stiff shoulder, that is, without a known cause. Secondary stiff shoulder is a &hellip; <a href=\"https:\/\/jocr.co.in\/wp\/2026\/09\/clinical-outcomes-of-clinico-radiologically-predetermined-patient-specific-multi-site-steroid-injection-in-primary-frozen-shoulder-a-prospective-case-series\/\">Continue reading &hellip;<\/a><\/p>\n","protected":false},"author":1,"featured_media":98258,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[8935],"tags":[4062,1223,7567,6245,7568],"class_list":["post-98272","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-volume-16-issue-9-september-2026","tag-adhesive-capsulitis","tag-anterior-approach","tag-betamethasone","tag-frozen-shoulder","tag-intra-articular-steroid-injection"],"_links":{"self":[{"href":"https:\/\/jocr.co.in\/wp\/wp-json\/wp\/v2\/posts\/98272","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/jocr.co.in\/wp\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/jocr.co.in\/wp\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/jocr.co.in\/wp\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/jocr.co.in\/wp\/wp-json\/wp\/v2\/comments?post=98272"}],"version-history":[{"count":2,"href":"https:\/\/jocr.co.in\/wp\/wp-json\/wp\/v2\/posts\/98272\/revisions"}],"predecessor-version":[{"id":98275,"href":"https:\/\/jocr.co.in\/wp\/wp-json\/wp\/v2\/posts\/98272\/revisions\/98275"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/jocr.co.in\/wp\/wp-json\/wp\/v2\/media\/98258"}],"wp:attachment":[{"href":"https:\/\/jocr.co.in\/wp\/wp-json\/wp\/v2\/media?parent=98272"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/jocr.co.in\/wp\/wp-json\/wp\/v2\/categories?post=98272"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/jocr.co.in\/wp\/wp-json\/wp\/v2\/tags?post=98272"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}