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When To Use Corticosteroid Injections for the Shoulder

Dr. J. G. Skedros, an orthopedic surgeon from the Utah Bone & Joint Center in Salt Lake City has prepared three articles on the use of corticosteroid injections. The topic is the painful shoulder.

This is the first of those three articles. The focus is on the diagnosis, use, and misuse of these injections. The hope is to move toward a more uniform set of guidelines for such injections.

Corticosteroid injections are more powerful than using oral (by mouth) nonsteroidal anti-inflammatory drugs (NSAIDs). Besides reducing swelling, steroid injections also increase hyaluronic acid (HA) in the joint. HA improves waste removal from the joint and improves nutrition to the joint.

Injections take three to five days for the full effect to be felt. The relief of painful symptoms is both a treatment and a diagnostic test. Timing and dose are important. Too many injections, too close together, and with too high of a dose can lead to problems. Overuse of this treatment is the most common misuse.

Nonfluorinated corticosteroids must be used to avoid tendon rupture and wasting of the tissues (skin, fat, muscles) around the area injected. Steroid injections should never be used when there is an active infection in the skin or tissues around the shoulder. Patients with poorly controlled diabetes are not good candidates for steroid injections.

There are many possible local and/or systemic effects of corticosteroid injections. The author reviews each one carefully. The local effects include arthropathy (joint destruction), rotator cuff tendon problems, cellular effects, and corticosteroid flare (worse symptoms).

Adverse systemic effects can include uterine bleeding and menstrual problems, diabetes (new case or worsening for patients with diabetes), and reduced immune function.

The authors conclude there is a need for standard guidelines in the use of corticosteroid injections of the shoulder. Agreement is needed about when to use injections and how much to use. Uniform guidelines would help reduce the adverse side effects. Proper injection could lead to better pain relief and improved shoulder function.

Later issues of this journal will present parts two and three of this series. Physical exam and imaging will be discussed. Techniques for giving the injections in specific shoulder conditions will be presented.

References: John G. Skedros, MD, and Todd C. Pitts. The Use and Misuse of Injectable Corticosteroids for the Painful Shoulder. In The Journal of Musculoskeletal Medicine. February 2008. Vol. 25. No. 2. Pp. 78-98.

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