***TASK*** the task is to summarize an input biomedical literature in six sentences 
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    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
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    Input: OBJECTIVE To determine whether arthrographic distension with a mixture of saline and steroid , in patients with painful stiff shoulder for at least 3 months , is better than placebo in improving function , pain , and range of motion at 3 , 6 , and 12 weeks . METHODS A r and omised , placebo controlled trial with participant and outcome assessor blinding in which shoulder joint distension with normal saline and corticosteroid was compared with placebo ( arthrogram ) . Outcome measures , assessed at 3 , 6 , and 12 weeks , included a shoulder-specific disability measure ( SPADI ) , a patient preference measure ( Problem Elicitation Technique ( PET ) ) , pain , and range of active motion . RESULTS From 96 potential participants , 48 were recruited . Four withdrew from the placebo group after the 3 week assessment and three subsequently received arthrographic distension with saline and steroid . At 3 weeks , significantly greater improvement in SPADI ( p = 0.005 ) , PET , overall pain , active total shoulder abduction , and h and behind back was found in participants in the joint distension and steroid group than in the placebo group . At 6 weeks the results of the intention to treat analysis favoured joint distension , although the between-group differences were only significant for improvement in PET ( difference in mean change in PET between groups = 45.9 ( 95 % CI 3.2 to 88.7 ) . Excluding the four withdrawals , the between-group differences for the disability and pain measures significantly favoured distension over placebo . At 12 weeks , both the intention to treat analysis and an analysis excluding the four withdrawals demonstrated a significantly greater improvement in PET score for the distension group . CONCLUSIONS Short term efficacy of arthrographic distension with normal saline and corticosteroid over placebo was demonstrated in patients with painful stiff shoulder 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 The histological changes found in the supraspinatus tendon have similarities with the findings in Achilles- , patellar- and extensor carpi radialis brevis (ECRB)-tendinopathy . In recent studies , we have found a vasculo-neural ingrowth in chronic painful Achilles and patellar tendinopathy , and demonstrated good short-term clinical effects with injections of the sclerosing substance polidocanol . In this collaborative two-centre pilot study , 15 patients ( 10 males and 5 females , mean age 46 years ) with a long duration of shoulder pain ( mean 28 months ) , and given the diagnosis chronic painful shoulder impingement syndrome , were included . They had tried rest , traditional rehabilitation exercises and multiple subacromial corticosteroid injections , without effect . We found vascularity ( neovessels ) in chronic painful , but not in pain-free , supraspinatus tendons , and prospect ively studied the clinical effects of ultrasound ( US ) and colour Doppler (CD)-guided injections of polidocanol , targeting the area with neovessels . The patients evaluated the amount of shoulder pain during horizontal shoulder activity on a visual analogue scale ( VAS ) , and satisfaction with treatment . Two ( median ) ( range 1–5 ) polidocanol treatments ( with 4–8 weeks in between ) were given . In four patients ( considered treatment failure ) , cortisone was injected into an inflamed subacromial bursa at one separate occasion weeks after the last polidocanol injection . At follow-up , 8 ( median ) ( range 4–17 ) months after the treatment , 14 patients were satisfied with the result . Using the visual analogue scale evaluation ( VAS ) , the pain dropped from 79 before treatment to 21 at follow-up ( P < 0.05 ) . In the short-term perspective , sclerosing polidocanol injections targeting the neovessels in the supraspinatus tendon and /or bursa wall seems to have a potential to reduce the pain during shoulder loading activity Background Hydrodilatation of the glenohumeral joint is by several authors reported to improve shoulder pain and range of motion for patients with adhesive capsulitis . Procedures described often involve the injection of corticosteroids , to which the reported treatment effects may be attributed . Any important contribution arising from the hydrodilatation procedure itself remains to be demonstrated . Methods In this r and omized trial , a hydrodilatation procedure including corticosteroids was compared with the injection of corticosteroids without dilatation . Patients were given three injections with two-week intervals , and all injections were given under fluoroscopic guidance . Outcome measures were the Shoulder Pain and Disability Index ( SPADI ) and measures of active and passive range of motion .  Seventy-six patients were included and groups were compared six weeks after treatment . The study was design ed as an open trial . Results The groups showed a rather similar degree of improvement from baseline . According to a multiple regression analysis , the effect of dilatation was a mean improvement of 3 points ( confidence interval : -5 to 11 ) on the SPADI 0–100 scale . T-tests did not demonstrate any significant between-group differences in range of motion . Conclusion This study did not identify any important treatment effects result ing from three hydrodilatations that included steroid compared with three steroid injections alone . Trial registration The study is registered in Current Controlled Trials with the registration number IS RCT N90567697 PURPOSE The study goal was to examine the targeting accuracy of subacromial injection to the shoulder and the influence of the location of the injected structure . TYPE OF STUDY A prospect i ve nonr and omized study . METHODS Fifty-three patients ( 56 shoulders ; 34 women and 19 men ; mean age , 74.5 years ; range , 49 to 91 ) with impingement signs ( Neer , Hawkins ) of at least 2 months ' duration received a subacromial injection of a mixture of 0.5 mL ( 2.5 mg ) betamethasone acetate and 3 mL of radiographic contrast material ( iotrolan ) and 7 mL of 1 % lidocaine using a lateral approach . Radiographs of the shoulder joint were taken immediately after the injection to determine the structure reached by the injection . Details of pain expressed as Neer and Hawkins impingement signs were obtained before and 15 minutes after the injection , and subjectively assessed using a 4-point self-administered pain score . Pain reduction result ing from subacromial and intradeltoid injection was compared . RESULTS Thirty-nine of the 56 injections ( 70 % ) were judged to have reached the subacromial bursa . Twelve ( 21 % ) were seen to have entered the deltoid muscle ; 2 ( 4 % ) were in the glenohumeral joint ; and 3 ( 5 % ) were subcutaneous . A comparison of subacromial bursal with intradeltoid injection showed no significant differences in pain reduction expressed as impingement signs ( 1.5 vs 1.7 in the Neer impingement sign and 1.6 vs 1.6 in the Hawkins impingement sign , respectively ) . CONCLUSIONS This study showed that subacromial injection was a relatively difficult procedure . A high incidence of injections that missed the subacromial bursa would be a sufficient reason to refrain from repeated usage of corticosteroids . These results also suggest that pain relief could be attained whether the injected material reached the subacromial bursa or the deltoid muscle . Successful pain relief after intradeltoid injection seems to call into question the diagnostic value of a positive Neer impingement test Twenty-six patients with frozen shoulder syndrome ( Stage 2 and 3 ) were included in this study conducted at Dr. Kariadi General Hospital , Semarang , Indonesia and r and omly allocated into 2 groups : 40 mg triamcinolone intra-articular injection and triamcinolone oral tablets . The result showed that triamcinolone intra-articular injection group " cured " rate was 5.8 times higher at week one compared to the triamcinolone tablet group . Sixty-two percent of the cases with triamcinolone intra-articular injection achieved their " cured " condition after one week of therapy , compared with only 14 % of the triamcinolone tablets group . We conclude that , intra-articular corticosteroid injection provide faster improvement compared to oral route 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 Objective To determine whether fluoroscopic guidance improves outcomes of injections for greater trochanteric pain syndrome . Design Multicentre double blind r and omised controlled study . Setting Three academic and military treatment facilities in the United States and Germany . Participants 65 patients with a clinical diagnosis of greater trochanteric pain syndrome . Interventions Injections of corticosteroid and local anaesthetic into the trochanteric bursa , using fluoroscopy ( n=32 ) or l and marks ( that is , “ blind ” injections ; n=33 ) for guidance . Main outcome measures Primary outcome measures : 0 - 10 numerical rating scale pain scores at rest and with activity at one month ( positive categorical outcome predefined as ≥50 % pain reduction either at rest or with activity , coupled with positive global perceived effect ) . Secondary outcome measures included Oswestry disability scores , SF-36 scores , reduction in drug use , and patients ’ satisfaction . Results No differences in outcomes occurred favouring either the fluoroscopy or blind treatment groups . One month after injection the average pain scores were 2.7 at rest and 5.0 with activity in the fluoroscopy group compared with 2.2 and 4.0 in the blind injection group . Three months after the injection , 15 ( 47 % ) patients in the blind group and 13 ( 41 % ) in the fluoroscopy group continued to have a positive outcome . Conclusion Although using fluoroscopic guidance dramatically increases treatment costs for greater trochanteric pain syndrome , it does not necessarily improve outcomes . Trial registration Clinical 
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Minor adverse events reported included transient post-injection pain , facial redness and warmth .
AUTHORS ' CONCLUSIONS Based upon moderate evidence from five trials , our review was unable to establish any advantage in terms of pain , function , shoulder range of motion or safety , of ultrasound-guided glucocorticoid injection for shoulder disorders over either l and mark-guided or intramuscular injection .
The lack of any added benefit of ultrasound guided subacromial bursal injection over glucocorticoid injection administered into the upper gluteal muscles of the buttock suggests that the benefits of glucocorticoid may arise through systemic rather than local effects .
Therefore , although ultrasound guidance may improve the accuracy of injection to the putative site of pathology in the shoulder , it is not clear that this improves its efficacy to justify the significant added cost