"Can't I have a cortisone shot in my shoulder?"

Physicians and patients are often tempted to try injection of the shoulder to see if this gives pain relief. While intra articular injection of steroids (like cortisone) may be of at least temporary benefit in lessening symptoms, each injection does carry the risk of infection as emphasized in these posts
Can injection infect the shoulder with Propionibacterium?
Should the painful shoulder arthroplasty be injected with corticosteroids?
Are shoulder injections safe before shoulder joint replacement and arthroscopy?
Injection can increase the risk of infection in rotator cuff repairs
Rotator cuff repair - does injection increase the risk of infection?


The authors of Does Pre-Operative Corticosteroid Injection Increase the Risk of Periprosthetic Joint Infection After Reverse Shoulder Arthroplasty? investigated the association between the timing of corticosterioid injection (CSI) for osteoarthritis and the incidence of periprosthetic infection (PJI) of a reverse total shoulder arthroplasty using a national, all-payer database.
Their analysis demonstrated a significantly increased risk of PJI at 90 days and at one year after surgery in patients who received CSI within one month prior to RSA. While the authors state that no significant increase in PJI risk was noted for patients who received CSI more than one month before their RSA, a plot of their data suggests that the average rate of PJI remains higher for all patients having CSI prior to RSA in comparison to those not having prior CSI

Alcohol abuse, chronic kidney disease, and depression were also identified as risk factors for PJI.

The types of organisms causing PJI in this series are not specified.

Comment: The rate of PJI after RSA is high: at least one in 14 patients in this series. There is usually no rush in proceeding with these joint replacements. Infection is worth avoiding to every extent possible.

The reasons why injections increase the risk of PHI are not known. Is it
(1) contamination by the needle taking bacteria from the skin and inoculating the joint?
(2) does the injection activate bacteria that are already existing in the shoulder?
(3) does the steroid diminish host resistance to the ever present risk of infection, or
(4) some combination of these and other factors.

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Here are some videos that are of shoulder interest
Shoulder arthritis - what you need to know (see this link).
How to x-ray the shoulder (see this link).
The ream and run procedure (see this link).
The total shoulder arthroplasty (see this link).
The cuff tear arthropathy arthroplasty (see this link).
The reverse total shoulder arthroplasty (see this link).
The smooth and move procedure for irreparable rotator cuff tears (see this link).
Shoulder rehabilitation exercises (see this link).

What about a cortisone shot?

Use of Intra-Articular Corticosteroids in Orthopaedics

This review of the evidence-based research on the efficacy of intra-articular corticosteroid injections of the osteoarthritic knee was inconclusive.
Combining intra-articular corticosteroid injection with a higher-dose anesthetic may compound chondrotoxic effects (that is risk the deterioration of the cartilage in the joint)
Compared with corticosteroid injections for osteoarthritis, intra-articular viscosupplements (e.g. Synvisc) have not shown a substantial difference in pain relief or functional outcomes.
Although rare and usually transient, systemic effects of intra-articular corticosteroid injections may occur and can be influenced by the type, frequency, and dosage of the corticosteroid used.
Practitioners are encouraged to use corticosteroid injections judiciously to treat pain and joint inflammation from osteoarthritis and inflammatory arthritis of large joints.

Comment: In addition to the concerns expressed above, there is concern that cortisone injections may increase the risk of infection in total joints. A common recommendation is that joint replacement should be avoided within three months of such an injection.
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Why not just give a cortisone shot?

Complications Associated with Intra-Articular and Extra-Articular Corticosteroid Injections

These authors review the complications associated with the common practice of cortisone injection.

They conclude:
*Side effects of corticosteroids can occur in association with both intra-articular and extra-articular injections.
*Less-severe reactions include skin reactions and flare responses.
*Although rare, worrisome complications such as infections, tendon ruptures, and osteonecrosis can occur.
*It is important to note the effect of corticosteroids on blood glucose levels, particularly for patients with diabetes.
*Corticosteroid injections have visual side effects with a known relation to central serous chorioretinopathy.

Comment: In our shoulder practice, cortisone injections are rarely used. The reasons are several: these steroids weaken connective tissues including tendons and articular cartilage, they increase the risk of periprosthetic infection, and they do not treat the common shoulder pathologies of cuff or degenerative joint disease.

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Are shoulder injections safe before shoulder joint replacement and arthroscopy?

The Timing of Elective Shoulder Surgery after Intra-articular Shoulder Injection Affects Postoperative Infection Risk

These authors queried a national insurance database to evaluate the association of preoperative intra-articular shoulder injection before shoulder arthroscopy and arthroplasty with the incidence of postoperative infection for surgeries performed between 2005 and 2012. Control cohorts were created for each study group by matching patients who underwent the same procedure without a preoperative injection to the study cohorts based on age, gender, obesity, diabetes and smoking.

Three shoulder arthroscopy cohorts were created: shoulders having arthroscopy within 3 months of ipsilateral shoulder injection, shoulders having arthroscopy between 3 and 12 months after ipsilateral shoulder injection, and matched control arthroscopy without prior injection. 

Three similar shoulder arthroplasty cohorts were created.

Infection rates within 3 and 6 months postoperatively were assessed using ICD-9 and CPT codes.

The incidence of infection after shoulder arthroscopy at 3 months (0.7%, OR 2.2, P < 0.0001) and 6 months (1.1%, OR 1.6, P = 0.003) was significantly higher in patients who underwent injection within the 3 months prior to arthroscopy compared to matched controls [Table 1A-B].

The incidence of infection after shoulder arthroplasty at 3 months (3.0%, OR 2.0, P = 0.007) and 6 months (4.6%, OR 2.0, P = 0.001) was significantly higher in patients who underwent injection within the 3 months prior to arthroplasty compared to matched controls [Table 2A-B].

There was no significant difference in infection rates in patients who underwent shoulder arthroscopy or arthroplasty between 3–12 months after injection compared to controls.

Comment: Patients often ask about having an injection to address their symptoms before proceeding with surgery. The data presented here suggest that injections within three months of surgery increase the risk of subsequent infection.

Because of the nature of the data base, we do not know details, such as what was injected, which organisms were responsible for the infections, and how serious the infections were. Nevertheless, we now have useful information that we can share with our patients who are asking for injections.

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Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

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What happens to the rotator cuff after a cortisone injection?

Incidence of full-thickness rotator cuff tear after subacromial corticosteroid injection: a 12-week prospective study.

These authors carried out a prospective study of 102 patients with chronic shoulder pain. Initial ultrasound revealed that 49 had full thickness rotator cuff tears - these patients were excluded from further study.

Of the remaining 53, 39 had supraspinatus tendinopathy (24 with partial thickness tears (19 bursal side and 5 intrasubstance)). 11 had bursitis and 3 had a joint effusion. 19 patients were male, average age 61 years, average duration of symptoms 10 months, active flexion 147 degrees.

All 53 patients received a subacromial injection of 40 mg. of triamcinolone acetone. Patients did not receive rehabilitation therapy. 

At 12 weeks ultrasound was repeated. 9 patients were found to have new full thickness cuff tears. 6 of the 24 patients identified has having had a partial thickness cuff tear at the initial evaluation progressed to a full thickness tear at 12 weeks after injection.  3 of the 29 patients without an initial partial thickness tear had a full thickness tear at 12 weeks after injection.

7 of the nine patients with new full thickness cuff tears had improved symptoms, the two that did not improve had larger sized tears.

31 of the 44 patients not developing full thickness cuff tears had improved symptoms.

In all  50 of the 53 patients recovered a normal range of motion. Symptoms were improved in 38.

The authors also had 7 patients in a "control group" in which cortisone was felt to be contraindicated (allergy, poorly controlled diabetes). All seven had supraspinatus tendinopathy, 3 had partial thickness tears. These shoulders received an injection of local anesthetic only. At 12 weeks there were no full thickness tears. All 7 had improved motion and 6 had improved symptoms.

Comment:  This study is of interest in that it revealed a very high incidence of rotator cuff pathology in chronically symptomatic shoulders, including almost half with full thickness tears. 

The authors conclude "Corticosteroid injection is highly effective in improving clinical symptoms of rotator cuff tendinopathy at 12 weeks." We are not sure this is what the data reveal - the results in the 'control' group of 7 shoulders (in which corticoids could not be given) were at least as good as those receiving triamcinolone. This would have been a more informative study if the patients had been randomized to receive either triamcinolone or local anesthetic alone. Without these data we cannot learn the role of the triamcinolone in tear progression or in symptom improvement.

Here's our attempt at a graphical presentation of their data

Thus from this study we cannot conclude that steroid injections are more effective than local anesthetic in improving symptoms. Nor can we come to conclusions about the possible role of steroid injections in the progression of cuff tears - although there were no new full thickness tears in the 'control' group, the numbers are too small to make a robust conclusion.

It is apparent that the authors have a robust methodology and are ideally positioned to answer questions such as

(1) in an randomized controlled study, are steroid injections are more effective than local anesthetic injections in improving range of motion and symptoms?

(2) in an randomized controlled study, are steroid injections are more likely than local anesthetic injections to be associated with tear progression?

Finally, this study reminds us that the symptoms experienced by a patient with a cuff tear may arise from a wide variety of causes, including (1) tension at the margin of the tear (as in tennis elbow), 

(2) subacromial abrasion of a prominent tuberosity or hypertrophic bursa, 

(3) weakness, (4) instability (5) stiffness or (6) cuff tear arthropathy. It is important to sort out the origin of the symptoms before launching a treatment program. For example, if the issue is limited range of motion a gentle rehabilitation program may be preferable to an injection or surgery.

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Use the "Search" box to the right to find other topics of interest to you.

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Steroid vs NSAID injection for shoulder pain

A double-blind randomized controlled trial comparing the effects of subacromial injection with corticosteroid versus NSAID in patients with shoulder impingement syndrome.

The inclusion criteria included shoulder pain with passive and/or active abduction, diagnosis of subacromial bursitis based on tenderness to palpation about the acromion, positive Neer’s sign, positive Hawkin’s sign, and pain exacerbated with the shoulder held in internal rotation. It is not clear how many of these had to be present for inclusion. As is pointed out recently, the diagnosis of 'impingement syndrome' can in most cases be replaced with a more specific anatomical diagnosis, because many of the 'classical' signs have been shown to be non-specific. While MRI imaging was not used in all patients, a number of patients meeting the inclusion criteria were found to have cuff tears.

Nevertheless, this study is of interest because it was a double-blinded randomized controlled clinical trial comparing the subacromial injection of either 40 mg triamcinolone or 60 mg of ketorolac.

While both group were improved, the authors noted that an injection of ketorolac resulted in greater improvements in the UCLA scale than an injection of triamcinolone at 4 weeks follow-up. They suggest that ketorolac may have fewer potential side effects that steroid injection.

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Injections for shoulder arthritis

At the outset, I should state that I don't employ injections of the shoulder in my practice. Yet, for completeness, the reader should know that injections are used by others for one of two purposes. First, some physicians inject a local anesthetic into the joint in an attempt to confirm that the symptoms are coming from the shoulder joint rather than from other sources, such as a pinched nerve in the neck. In this application, the effect of the local anesthetic wears off soon afterwards, but the temporary relief of pain from an injection in the joint indicates that the pain is coming from the joint. Second, some physicians inject the shoulder in an attempt to provide some more lasting relief of pain. Two types of injections have been used: (1) steroids (like cortisone) and (2) viscosupplementation (like hyaluronic acid). For the interested reader, two reviews of these types of injections for osteoarthritis were published in 2006:

*Stitik, T. P., A. Kumar, et al. (2006). "Corticosteroid injections for osteoarthritis." Am J Phys Med Rehabil 85(11 Suppl): S51-65
*Stitik, T. P. and J. A. Levy (2006). "Viscosupplementation (biosupplementation) for osteoarthritis." Am J Phys Med Rehabil 85(11 Suppl): S32-50.

While these injections may provide symptomatic relief, a recent review of guidelines for the treatment of shoulder arthritis (Izquierdo, R., I. Voloshin, et al. "Treatment of glenohumeral osteoarthritis." J Am Acad Orthop Surg 18(6): 375-82.) failed to find substantial evidence in favor of their effectiveness. Similarly, a Cochrane review did not find evidence supporting the use of cortisone injections for shoulder pain (Buchbinder, R., S. Green, et al. (2003). "Corticosteroid injections for shoulder pain." Cochrane Database Syst Rev(1): CD004016.).

However, several relatively recent articles have provided some indication of the benefit of viscosupplementation for shoulder arthritis:

*Brander, V. A., A. Gomberawalla, et al. "Efficacy and safety of hylan G-F 20 for symptomatic glenohumeral osteoarthritis: a prospective, pilot study." PM R 2(4): 259-67.
*Noel, E., P. Hardy, et al. (2009). "Efficacy and safety of Hylan G-F 20 in shoulder osteoarthritis with an intact rotator cuff. Open-label prospective multicenter study." Joint Bone Spine 76(6): 670-3.
*Silverstein, E., R. Leger, et al. (2007). "The use of intra-articular hylan G-F 20 in the treatment of symptomatic osteoarthritis of the shoulder: a preliminary study." Am J Sports Med 35(6): 979-85.

Finally, it is important to note that in cases of shoulder joint infection, a high percentage appear to follow injections of the shoulder, so caution is advised:

*Rhee, Y. G., N. S. Cho, et al. (2008). "Injection-induced pyogenic arthritis of the shoulder joint." J Shoulder Elbow Surg 17(1): 63-7.
*Esenwein, S. A., T. Ambacher, et al. (2002). "[Septic arthritis of the shoulder following intra-articular injection therapy. Lethal course due to delayed initiation of therapy]." Unfallchirurg 105(10): 932-8.
*Leslie, B. M., J. M. Harris, 3rd, et al. (1989). "Septic arthritis of the shoulder in adults." J Bone Joint Surg Am 71(10): 1516-22.

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