Original research| Volume 101, ISSUE 10, P1689-1695, October 2020

Download started.


Comparison of the Effects of Vapocoolant Spray and Topical Anesthetic Cream on Pain During Intraarticular Injection of the Shoulder: A Randomized Double-Blind Controlled Trial



      This study was performed to compare the effects of a vapocoolant spray and a eutectic mixture of local anesthetics (EMLA) cream on reducing pain during intra-articular (IA) injection of the shoulder.


      Double-blind randomized placebo-controlled clinical trial.


      University hospital.


      Patients (N=63) who underwent IA injection of the shoulder joint were randomized into the spray group, EMLA group, or placebo group.


      Placebo cream+vapocoolant spray (spray group), EMLA cream+placebo spray (EMLA group), or placebo cream+placebo spray (placebo group) before IA injection.

      Main Outcome Measures

      A 100-mm visual analog scale (VAS) for injection pain and 5-point Likert scales for participant satisfaction and preference for repeated use were administered immediately after IA injection.


      The VAS scores for pain during IA injection were 30.0 (95% CI, 19.7-41.2) in the spray group, 50.0 (95% CI, 37.7-63.0) in the EMLA group, and 53.8 (95% CI, 41.6-65.0) in the placebo group (F=6.403, P<.01). The spray group showed significantly better Likert scale scores than the placebo group for participant satisfaction (P=.003) and preference for repeated use (P<.001).


      Vapocoolant spray was effective in reducing pain during IA injection of the shoulder.


      List of abbreviations:

      EMLA (eutectic mixture of local anesthetics), HA (hyaluronic acid), IA (intra-articular), SPADI (Shoulder Pain and Disability Index), VAS (visual analog scale)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Issa S.N.
        • Sharma L.
        Epidemiology of osteoarthritis: an update.
        Curr Rheumatol Rep. 2006; 8: 7-15
        • Chillemi C.
        • Franceschini V.
        Shoulder osteoarthritis.
        Arthritis. 2013; 2013: 370231
        • Kerr R.
        • Resnick D.
        • Pineda C.
        • Haghighi P.
        Osteoarthritis of the glenohumeral joint: a radiologic-pathologic study.
        Am J Roentgenol. 1985; 144: 967-972
        • Zhang B.
        • Thayaparan A.
        • Horner N.
        • Bedi A.
        • Alolabi B.
        • Khan M.
        Outcomes of hyaluronic acid injections for glenohumeral osteoarthritis: a systematic review and meta-analysis.
        J Shoulder Elbow Surg. 2019; 28: 596-606
        • Beukelman T.
        • Guevara J.P.
        • Albert D.A.
        • Sherry D.D.
        • Burnham J.M.
        Usage of intra-articular corticosteroid injections for the treatment of juvenile idiopathic arthritis: a survey of pediatric rheumatologists in the United States and Canada.
        Clin Exp Rheumatol. 2008; 26: 700-703
        • Chavez-Chiang C.E.
        • Sibbitt Jr., W.L.
        • Band P.A.
        • Chavez-Chiang N.R.
        • DeLea S.L.
        • Bankhurst A.D.
        The highly accurate anteriolateral portal for injecting the knee.
        Sports Med Arthrosc Rehabil Ther Technol. 2011; 3: 6
        • Zhu Y.
        • Peng X.
        • Wang S.
        • et al.
        Vapocoolant spray versus placebo spray/no treatment for reducing pain from intravenous cannulation: a meta-analysis of randomized controlled trials.
        Am J Emerg Med. 2018; 36: 2085-2092
        • Firdaus R.
        • Sukmono B.
        • Melati A.C.
        • Marzaini B.D.
        Comparison between vapocoolant spray and eutectic mixture of local anesthetics cream in reducing pain during spinal injections.
        Anesthesiol Res Pract. 2018; 2018: 5050273
        • Irkoren S.
        • Ozkan H.S.
        • Karaca H.
        A clinical comparison of EMLA cream and ethyl chloride spray application for pain relief of forehead botulinum toxin injection.
        Ann Plast Surg. 2015; 75: 272-274
        • Weiss J.E.
        • Uribe A.G.
        • Malleson P.N.
        • Kimura Y.
        Anesthesia for intra-articular corticosteroid injections in juvenile idiopathic arthritis: a survey of pediatric rheumatologists.
        Pediatr Rheumatol Online J. 2010; 8: 3
        • Price D.D.
        • Bush F.M.
        • Long S.
        • Harkins S.W.
        A comparison of pain measurement haracteristics of mechanical visual analogue and simple numerical rating scales.
        Pain. 1994; 56: 217-226
        • Roach K.E.
        • Budiman-Mak E.
        • Songsiridej N.
        • Lertratanakul Y.
        Development of a shoulder pain and disability index.
        Arthritis Care Res. 1991; 4: 143-149
        • Zeiderman M.R.
        • Kelishadi S.S.
        • Tutela J.P.
        • et al.
        Vapocoolant anesthesia for cosmetic facial rejuvenation injections: a randomized, prospective, split-face trial.
        Eplasty. 2018; 18: e6
        • Griffith R.J.
        • Jordan V.
        • Herd D.
        • Reed P.W.
        • Dalziel S.R.
        Vapocoolants (cold spray) for pain treatment during intravenous cannulation.
        Cochrane Database Syst Rev. 2016; 4: CD009484
        • Armstrong P.
        • Young C.
        • McKeown D.
        Ethyl chloride and venepuncture pain: a comparison with intradermal lidocaine.
        Can J Anaesth. 1990; 37: 656-658
        • Kunesch E.
        • Schmidt R.
        • Nordin M.
        • Wallin U.
        • Hagbarth K.E.
        Peripheral neural correlates of cutaneous anaesthesia induced by skin cooling in man.
        Acta Physiol Scand. 1987; 129: 247-257
        • Im Y.G.
        • Park H.J.
        • Chae H.Y.
        • et al.
        Comparison of changes in facial skin temperature caused by ethyl chloride spraying, ice block rubbing and cold gel packing in healthy subjects.
        J Oral Rehabil. 2012; 39: 931-940
        • Wagner B.S.
        • Howe A.S.
        • Dexter W.W.
        • et al.
        Tolerability and efficacy of 3 approaches to intra-articular corticosteroid injections of the knee for osteoarthritis: a randomized controlled trial.
        Orthop J Sports Med. 2015; 3 (2325967115600687)
        • Shah A.
        • Vidoni A.
        • McGarry S.
        • Davies M.
        • James S.
        • Botchu R.
        Ethyl chloride spray for musculoskeletal ultrasound-guided injections: an alternative to subcutaneous injection of local anesthetic solution.
        J Clin Ultrasound. 2018; 46: 129-131
        • Lander J.
        • Hodgins M.
        • Nazarali S.
        • McTavish J.
        • Ouellette J.
        • Friesen E.
        Determinants of success and failure of EMLA.
        Pain. 1996; 64: 89-97
        • Hahn I.H.
        • Hoffman R.S.
        • Nelson L.S.
        EMLA-induced methemoglobinemia and systemic topical anesthetic toxicity.
        J Emerg Med. 2004; 26: 85-88
        • Moon Y.E.
        • Kim S.H.
        • Choi W.H.
        Comparison of the effects of vapocoolant spray and topical anesthetic cream on pain during needle electromyography in the medial gastrocnemius.
        Arch Phys Med Rehabil. 2013; 94: 919-924
        • Wahlgren C.F.
        • Quiding H.
        Depth of cutaneous analgesia after application of a eutectic mixture of the local anesthetics lidocaine and prilocaine (EMLA cream).
        J Am Acad Dermatol. 2000; 42: 584-588
        • Todd K.H.
        • Funk K.G.
        • Funk J.P.
        • Bonacci R.
        Clinical significance of reported changes in pain severity.
        Ann Emerg Med. 1996; 27: 485-489
        • Conduah A.H.
        • Baker C.L.
        • Baker C.L.
        Managing joint pain in osteoarthritis: safety and efficacy of hylan G-F 20.
        J Pain Res. 2009; 2: 87-98
        • Strauss E.J.
        • Hart J.A.
        • Miller M.D.
        • Altman R.D.
        • Rosen J.E.
        Hyaluronic acid viscosupplementation and osteoarthritis: current uses and future directions.
        Am J Sports Med. 2009; 37: 1636-1644
        • Burney K.
        • Bowker K.
        • Reynolds R.
        • Bradley M.
        Topical ethyl chloride fine spray. Does it have any antimicrobial activity?.
        Clin Radiol. 2006; 61: 1055-1057
        • Polishchuk D.
        • Gehrmann R.
        • Tan V.
        Skin sterility after application of ethyl chloride spray.
        J Bone Joint Surg Am. 2012; 94: 118-120