Celestone versus Ketorolac Injection for the Treatment of DeQuervains Tenosyovitis: Results of a Double-Blind Randomized Clinical Trial
Lisa Kruse, MD1; Glenn Gaston, MD1; Bryan Loeffler, MD2; Daniel R Lewis, MD1; R Christopher Chadderdon, MD3; (1)OrthoCarolina Hand Center, Charlotte, NC, (2)Hand Center, OrthoCarolina Hand Center, Charlotte, NC, (3)OrthoCarolina, Charlotte, NC
Background: While the mechanism of action is unclear, injectable corticosteroids, primarily betamethasone, are a well-accepted treatment of DeQuervain's tenosynovitis, but are contraindicated for diabetics with elevated blood glucose. If steroids are effective for DeQuervain's because of their anti-inflammatory properties, then there is a reasonable argument for local injection of ketorolac, a non-steroidal anti-inflammatory drug (NSAID), which is efficacious in shoulder pathology and not contraindicated in diabetics.
Methods: Following informed consent, DeQuervain's tenosynovitis patients were randomized to an injection of corticosteroid (betamethasone) or NSAID (ketorolac). The investigator and patient were blinded to randomization; an un-blinded research coordinator prepared the injection in an unlabeled syringe. The primary study outcome was pain with Finklestein test at 6 weeks post-injection. Patients that had not improved at 6 weeks were provided an injection of betamethasone as standard-of-care, regardless of initial randomization. Other outcomes of interest included pain with palpation and patient-reported outcomes (Veterans RAND 12 Item Health Survey (VR-12) and Disabilities of the Arm, Shoulder, and Hand (DASH) scores).
Results: 37 patients (Mean Age: 53.5 years) with six-week follow-up were randomized to betamethasone (n=18; 49%) or ketorolac (n=19; 51%) injection. While there was no significant difference in pain at baseline with Finkelstein test (p=0.614) and palpation (p=0.970), patients in the betamethasone group had lower pain at 6 weeks with the Finkelstein test (27.8/100 vs. 44.6/100; p=0.072) and palpation (25.8/100 vs. 48.7/100; p=0.024). Over half of patients in the ketorolac group required an additional injection at six-weeks, compared to one-third in the betamethasone group (10/19=52.6% vs. 6/18=33.3%; p=0.197). While there was no significant difference in the VR-12 between groups at six weeks (physical component: p=0.526; mental component: p=0.899), DASH disability/symptom (11.1 vs. 32.5; p=0.002) and work (12.1 vs. 27.92; p=0.052) scores were significantly better in the betamethasone group (there was no significant difference in baseline scores (p=0.398 disability/symptom and p=0.939 work)).
Conclusions: Patients randomized to betamethasone injection had significantly lower pain scores at six weeks, compared to patients randomized to ketorolac injection. Patients receiving betamethasone injections also had better patient-reported outcomes at six weeks, compared to patients receiving ketorolac. While not statistically significant, patients randomized to the ketorolac group (10/19) were more likely to require a second injection compared to patients randomized to betamethasone (6/18).
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