Review article (meta-analysis)| Volume 99, ISSUE 7, P1383-1394.e6, July 2018

Comparative Efficacy of Intra-Articular Steroid Injection and Distension in Patients With Frozen Shoulder: A Systematic Review and Network Meta-Analysis

  • Meng-Ting Lin
    Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
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  • Ming-Yen Hsiao
    Corresponding author Ming-Yen Hsiao, MD, Departments of Physical Medicine and Rehabilitation, National Taiwan University Hospital, College of Medicine, National Taiwan University, No 7, Zhongshan S Rd, Taipei 100, Taiwan.
    Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
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  • Yu-Kang Tu
    Graduate Institute of Epidemiology and Preventive Medicine, National Taiwan University College of Public Health, Taipei, Taiwan
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  • Tyng-Guey Wang
    Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
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Published:September 09, 2017DOI:



      To compare the efficacy of intra-articular (IA) steroid injection and distension in patients with frozen shoulder.

      Data Sources

      Databases, including MEDLINE (via PubMed), Embase, Scopus, and Cochrane Library, were searched for studies published up to November 2016.

      Study Selection

      We included all published randomized controlled trials (RCTs), quasi-experimental studies, and observational studies investigating the effectiveness of IA steroid injection, distension, and physiotherapy in patients with frozen shoulder. Sixteen RCTs and 1 observational study were enrolled in meta-analysis.

      Data Extraction

      Full texts were independently reviewed, and quality of RCTs was assessed with The Cochrane Collaboration's tool. The primary outcome was functional improvement; the secondary outcomes included pain reduction and external rotation (ER) improvement.

      Data Synthesis

      In pairwise meta-analysis, pooled standardized mean difference (SMD) of functional improvement and pain reduction revealed equal efficacy at 3 follow-up time points. With respect to ER improvement, distension has a superior effect compared with IA steroid injection in the short term [(2–4wk; SMD, −.36; 95% confidence interval [CI], −.68 to −.04) and medium term (6–16wk; SMD, −0.80; 95% CI, −1.32 to −0.29). The network meta-analysis indicated a better efficacy for distension than for IA steroid injection in ER improvement only in the medium term (6–16wk; SMD, −0.70; 95% CI, −1.19 to −0.21).


      IA steroid injection was as effective as distension in shoulder function improvement, pain reduction, and increasing ER of the shoulder. Distension yielded better ER improvement in the medium term but to a minor extent in the long term. For patients with predominant ER limitation, early distension could be considered the primary choice of treatment.


      List of abbreviations:

      ER (external rotation), IA (intra-articular), PT (physiotherapy), RCT (randomized controlled trial), ROM (range of motion), SMD (standardized mean difference)
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