Bolulinum Works as Well as Steroid in Frozen Shoulder – Isn’t it About Time We Think About Combining The Two?

A recent article shows that botulinum  and steroid have similar durations of action in adhesive capsulitis – ie Frozen Shoulder. I have given both triamcinolone and botulinum (at separate times) into knee joints and noticed the combination can cause a profound improvement.  Why not use both?

Ann Rehabil Med. 2013 Apr;37(2):208-214.
A Comparison of the Short-Term Effects of a Botulinum Toxin Type A and Triamcinolone Acetate Injection on Adhesive Capsulitis of the Shoulder.
Joo YJ, Yoon SJ, Kim CW, Lee JH, Kim YJ, Koo JH, Song SH.

  • Cases resistant to physio and NSAID’s
  • 20 mg triamcinolone or 200 units Dysport = about 65 units botox if consider 3:1 ratio
    Neurol Sci. 2013 Apr 11. [Epub ahead of print]
    Conversion ratio between Dysport and Botox in clinical practice: an overview of available evidence.
    Ravenni R, De Grandis D, Mazza A.
  • Used dye imaging to confirm injection
  • Results:

Proposed Mechanisms of Action: (direct quotes):

  • inhibition of alpha- and gamma-motor neurons
  •  inhibition of the release of local nociceptive neuropeptides/agents via vesicle-dependent exocytosis
  • reduction in the release of a number of pain neurotransmitters, including substance P, CGRP, and bradykinin
  • the reduction in neurogenic inflammation,
  • alterations within the autonomic nervous system which result in changes to regional perfusion
  • central changes affecting behavior and stress,
  • alterations in the sensory pattern within the central nervous system
  • affect the cell cycle distribution of the fibroblast
  • Ability to reduce adhesions and fibrosis.

Side Effects – Non noteworthy – one botulinum case had a temporary flu like reaction, and 2 of the triamcinolone had some flushing for a while after.

Comment – Proves to me just how much neurogenic inflammation is involved in shoulder pain – I also like to give suprascapular nerve blocks with my shoulder injections and think the neuroblockade helps as well.  Given that these were the most resistant cases, the results are significant by the term “One Shot Wonder”. I think you have to be God for one shot to fix everything and authors are deluding themselves if they think one will do. Cyriax reported more than one was necessary and a more recent author found good results with three:
At Last Some Sense In Shoulder Injections – Three Shots

As I mentioned before, I have seen better results in knee when both were used ( though I never drew up in same injection). With cases this bad, maybe that needs consideration. Must admit, I use 40 mg triamcinolone into shoulder, and would love to see if 20 mg is as effective..

Any comments?

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