***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: OBJECTIVE To study the effect of accuracy on the clinical outcome of local steroid injections to the shoulder . METHODS 37 patients with shoulder symptoms of at least two months ’ duration received local injections of a mixture of triamcinolone and radiographic contrast material using a st and ardised technique . Radiographs of the joint were taken immediately afterwards . Details of the patients ’ symptoms ( assessed by visual analogue scales ) and range of movement at the joint were obtained before and two weeks after the injection . At follow up the patients were also assessed by means of a five point global rating scale of maximum and current benefit . RESULTS 14 of the 38 procedures ( 37 % ) were judged to be accurately placed : four of the 14 attempted subacromial injections ( 29 % ) and 10 of the 24 attempted glenohumeral injections ( 42 % ) . There were significant differences in relation to outcome between the accurately placed and the inaccurately placed groups . CONCLUSIONS Accuracy of steroid placement by injection in patients with shoulder symptoms may significantly affect the clinical outcome Background Blind injection of the subacromial-sub-deltoid bursa ( SSB ) for diagnostic purpose s ( Neer test ) or therapeutic purpose s ( corticosteroid therapy ) is frequently used . Poor response to previous blind injection or side effects may be due to a misplaced injection . It is assumed that ultrasound (US)-guided injections are more accurate than blind injections . In a r and omized study , we compared the accuracy of blind injection to that of US-guided injection into the SSB . Patients and methods 20 consecutive patients with impingement syndrome of the shoulder were r and omized for blind or US-guided injection  in the SSB . Injection was performed either by an experienced orthopedic surgeon or by an experienced musculoskeletal radiologist . A mixture of 1 m’L methylprednisolone acetate , 4 mL prilocaine hydrochloride and 0.02 mL ( 0.01 mmol ) Gadolinium DTPA was injected . Immediately after injection , a 3D-gradient T1-weighted magnetic resonance scan of the shoulder was performed . The location of the injected fluid was independently assessed by 2 radiologists who were blinded as to the injection technique used . Results The accuracy of blind and US-guided injection was the same . The fluid was injected into the bursa in all cases . Interpretation Blind injection into the SSB is as reliable as US-guided injection and could therefore be used in daily routine . US-guided injections may offer a useful alternative in difficult cases , such as with changed anatomy postoperatively or when there is no effective clinical outcome Objective To compare the effectiveness of ultrasound guided corticosteroid injection in the subacromial bursa with systemic corticosteroid injection in patients with rotator cuff disease . Design Double blind r and omised clinical trial . Setting Outpatient clinic of a physical medicine and rehabilitation department in Oslo , Norway . Patients 106 patients with rotator cuff disease lasting at least three months . Interventions Ultrasound guided corticosteroid and lidocaine injection in the subacromial bursa and lidocaine injection in the gluteal region ( local group ) ; corticosteroid and lidocaine injection in the gluteal region and ultrasound guided lidocaine injection in the subacromial bursa ( systemic group ) . Main outcome measures Difference in improvement in the overall shoulder pain and disability index score after six weeks . Results Six weeks after the intervention , the mean difference in improvement in overall shoulder pain and disability index score between the local group and the systemic group was −5.2 ( 95 % confidence interval −13.9 to 3.5 ) ; it was −4.1 ( −12.3 to 4.1 , P=0.32 ) after adjustment for baseline score . A small but statistically significant difference in improvement between groups occurred in favour of the local group for two secondary outcome measures : the Western Ontario rotator cuff index ( 8.1 , 0.7 to 15.6 ) and change in main complaint ( 2.0 , 0 to 4 ) . Conclusions No important differences in short term outcomes were found between local ultrasound guided corticosteroid injection and systemic corticosteroid injection in rotator cuff disease . Trial registration Clinical trials NCT00640575 Aim To compare the effectiveness of l and mark-guided local injections and ultrasonography ( USG ) guided injections for shoulder pain . Methods A total 60 consecutive patients with shoulder pain due to soft tissue disorders was enrolled , and r and omly assigned to receive triamcinolone ( 40 mg ) either by l and mark-guided ( LMG , n=30 ) or USG guided ( n=30 ) injection . The patients were evaluated on admission and 6 weeks after the injection . Clinical assessment included demographic and clinical data , a visual analoge scale ( VAS ) for pain ( 0 to 10 cm ) , the Constant scale ( 0 to 100 ) for function , passive and active shoulder range of motion ( ROM ) with goniometric evaluation , and postinjection adverse effects . Results Initial demographic , clinical and USG findings in the groups exhibited no significant differences . Six weeks after injection , the VAS and the Constant score showed a significantly better improvement in USG group compared with LMG group ( mean VAS score decrease : 4.0±1.7 for USG vs. 2.2±0.9 for LMG , P<0.05 ; mean Constant score change : 32.2 for USG vs. 12.2 for LMG , P<0.05 ) . Significant improvements were observed in active and passive ROM values in both groups , USG group values being better . Initially 18 patients in LMG and 24 patients in USG had limited shoulder ROM , of which 6 was returned to normal values in LMG group and 12 in USG group at 6 week after injection ( P<0.05 ) . Conclusions Our results indicate that the injection of corticosteroids to patients with shoulder pain due to soft tissue disorders under the USG-guidance may improve therapeutic effectiveness and reduce adverse effects Chen MJL , Lew HL , Hsu TC , Tsai WC , Lin WC , Tang SFT , Lee YC , Hsu RCH , Chen CPC : Ultrasound-guided shoulder injections in the treatment of subacromial bursitis . Am J Phys Med Rehabil 2006;85:31–35 . Objective : To investigate the treatment effectiveness between ultrasound-guided and blind injection techniques in the treatment of subacromial bursitis . Design : A total of 40 patients with sonographic confirmation of subacromial bursitis were recruited into this study . These patients were divided into blind and ultrasound-guided injection groups . The shoulder abduction range of motion was compared before injections and 1 wk after the completion of injections in both groups . Results : The shoulder abduction range of motion before injection in the blind injection group was 71.03 ± 12.38 degrees and improved to 100 ± 18.18 degrees 1 wk after the injection treatments . However , the improvement did not reveal significant statistical differences ( P > 0.05 ) . The shoulder abduction range of motion before injection in the ultrasound-guided injection group was 69.05 ± 14.72 degrees and improved to 139.29 ± 20.14 degrees 1 wk after the injection treatments ( P < 0.05 ) . Conclusions : Ultrasound may be used as an adjuvant tool in guiding the needle accurately into the inflamed subacromial bursa . The ultrasound-guided injection technique can result in significant improvement in shoulder abduction range of motion as compared with the blind injection technique in treating patients with subacromial bursitis PURPOSE To assess the accuracy of shoulder infiltrations in the subacromial bursa ( SAB ) by a posterior or an anteromedial approach . Magnetic resonance imaging ( MRI ) and clinical outcome were used for evaluation . TYPE OF STUDY A prospect i ve r and omized study . METHODS Thirty-three patients ( 22 women , 11 men ; average age , 46 years ; range , 25 to 64 years ) with clinical signs of subacromial impingement were infiltrated with a mixture of bupivacaine , methylprednisolone , and gadolinium-DTPA directly followed by MRI to determine the actual site of injection . The SAB was r and omly infiltrated posteriorly ( n = 17 ) or anteromedially ( n = 16 ) . Injection confidence of the surgeon and body-mass index of the patient were recorded . Follow-up consisted of the Constant Score , Simple Shoulder Test , and visual analog scale score for pain taken within 24 hours and 6 weeks after infiltration . RESULTS Thirteen injections ( 76 % ) were in the SAB with a posterior approach and 10 ( 69 % ) with an anteromedial approach . Many surrounding structures were hit as well , especially the rotator cuff . A positive correlation between the injection confidence of the orthopaedic surgeon and the MRI was found in 66 % . Only injection of the SAB alone result ed in a significant decrease of the pain ( P = .004 ) and an increase in the functional scores . Injection in the bursa and rotator cuff muscle showed a significant increase in pain ( P = .032 ) but no change in clinical scores . The body mass index had no influence on the scores . CONCLUSIONS Injections in the SAB are inaccurate , despite the confident feeling of the clinician . The finding that many different structures can be infiltrated with 1 injection can create both false-positive and -negative results . LEVEL OF EVIDENCE Level II Objective . This r and omized controlled study addressed whether sonographic needle guidance affected clinical outcomes of intraarticular ( IA ) joint injections . Methods . In total , 148 painful joints were r and omized to IA triamcinolone acetonide injection  by conventional palpation-guided anatomic injection or sonographic image-guided injection enhanced with a one-h and ed control syringe ( the reciprocating device ) . A one-needle , 2-syringe technique was used , where the first syringe was used to introduce the needle , aspirate any effusion , and anesthetize and dilate the IA space with lidocaine . After IA placement and synovial space dilation were confirmed , a syringe exchange was performed , and corticosteroid was injected with the second syringe through the indwelling IA needle . Baseline pain , procedural pain , pain at outcome ( 2 weeks ) , and changes in pain scores were measured with a 0–10 cm visual analog pain scale ( VAS ) . Results . Relative to conventional palpation-guided methods , sonographic guidance result ed in 43.0 % reduction in procedural pain ( p < 0.001 ) , 58.5 % reduction in absolute pain scores at the 2 week outcome ( p < 0.001 ) , 75 % reduction in significant pain ( VAS pain score ≥ 5 cm ; p < 0.001 ) , 25.6 % increase in the responder rate ( reduction in VAS score ≥ 50 % from baseline ; p < 0.01 ) , and 62.0 % reduction in the nonresponder rate ( reduction in VAS score < 50 % from baseline ; p < 0.01 ) . Sonography also increased detection of effusion by 200 % and volume of aspirated fluid by 337 % . Conclusion . Sonographic needle guidance significantly improves the performance and outcomes of outpatient IA injections in a clinical ly significant manner OBJECTIVE Local corticosteroid injections , commonly accepted by rheumatologists to be effective treating painful shoulder , have shown controversial results . High frequency ultrasonography is an accurate and safe imaging modality for guiding musculoskeletal injections . We prospect ively compared the short term response to r and omized blind injection versus sonographic-guided injection of local corticosteroid in patients with painful shoulder . METHODS We studied 41 consecutive patients with painful shoulder . Patients with previous trauma or chronic inflammatory arthritis were excluded . No patient had received previous physiotherapy or local steroid injection in the shoulder . Patients were r and omized to receive either a blind subacromial injection of 20 mg triamcinolone ( Group 1 , n = 20 ) or a sonographic guided injection of 20 mg triamcinolone ( Group 2 , n = 21 ) by the same rheumatologist blinded to the clinical evaluation . In both groups we recorded shoulder abnormalities and the location of the steroid postinjection by ultrasound . Each patient was clinical ly assessed within 5 days before injection and 6 weeks after injection by another rheumatologist without knowledge of the injection technique performed . Clinical assessment included demographic and clinical data , a visual analog scale ( VAS ) for pain ( 0 - 100 ) , the Shoulder Function Assessment ( SFA ) scale ( 0 - 70 ) , and postinjection adverse effects . No patient received physical therapy during the followup period . Initially , demographic , clinical , and ultrasonographic findings in both groups showed no significant differences . RESULTS Six weeks after injection , the VAS and the SFA score showed a significantly greater improvement in Group 2 compared with Group 1 ( mean VAS score change 34.9 for Group 2 vs 7.1 for Group 1 , p < 0.001 ; and mean SFA score change 15 for Group 2 vs 5.6 for Group 1 , p = 0.012 ) . One patient in Group 1 reported mild postinjection adverse effects . CONCLUSION We suggest that sonographic-guided corticosteroid injections should be indicated , at least , in patients with poor response to previous blind injection to ensure accurate medication placement in order to improve therapeutic effectiveness UNLABELLED Lee H-J , Lim K-B , Kim D-Y , 
    Output:
    
In this review , patients who underwent image-guided ( ultrasound ) injections had statistically significant greater improvement in shoulder pain and function at 6 weeks after injection .
Image-guided ( ultrasound ) corticosteroid injections potentially offer a significantly greater clinical improvement over blind ( l and mark-guided ) injections in adults with shoulder pain .