"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).

Can injection infect the shoulder with Propionibacterium?

The colonisation of the glenohumeral joint by Propionibacterium acnes is not associated with frozen shoulder but is more likely to occur after an injection into the joint

These authors investigated the prevalence of Propionibacterium (P.) acnes in the subcutaneous fat and capsule of 46 patients undergoing shoulder surgery for frozen shoulder or instability. Patients were asked if they have ever had an injection into the shoulder to be operated on, including an injection of contrast for MR arthrogram.

25 patients (53%) had P. acnes in one or more tissue samples and 35 (74%) had other bacterial species. The same microbe was found in the subcutaneous fat and the capsule in 13 patients (28%). 

Male gender was significantly associated with an increased capsular colonisation of P. acnes (odds ratio (OR) 12.38, 95% confidence interval (CI) 1.43 to 106.77, p = 0.02). 

A pre-operative glenohumeral intra-articular injection - either as treatment for a frozen shoulder or for the injection of contrast in patients with instability - was significantly associated with capsular P. acnes colonisation (OR 5.63, 95% CI 1.07 to 29.61, p = 0.04. 

Positive fat colonisation with P. acnes was significantly associated with capsular P. acnes (OR 363, 95% CI 20.90 to 6304.19, p < 0.01). 

Patients who had a pre-operative glenohumeral injection who were found intra-operatively to have fat colonisation with P. acnes had a statistically significant association with colonisation of their capsule with P. acnes (OR 165, 95% CI 13.51 to 2015.24, p < 0.01).

These authors concluded that there was a statistically significant association between subcutaneous skin P. acnes culture and P. acnes capsular culture, especially when the patient has undergone a previous injection. 

Comment: This paper provides additional evidence that any invasion of the joint, even an injection, may introduce Propionibacterium into the shoulder. This paper does not provide data on how long prior to the surgery the injections were performed. There is a common believe that shoulder arthroplasty shoulder not be performed within three months of an injection. However, there is no evidence that Propionibacterium introduced by an infection would have been eliminated by host defenses in that period of time. Thus we must ask, does the risk of shoulder colonization after injection decrease with time after injection, or is it long standing?

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How you can support progress in shoulder surgery

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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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How you can support progress in shoulder surgery

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'

Is there such a thing as injection arthropathy?

We often see patients whose physicians have tried to delay the need for arthroplasty through the use of injections (steroids, PRP, hylaluronic acid) The safety and efficacy of these injections is unclear (see this link, this link, this link, this link, this link, and this link). Laboratory investigations, such as Lidocaine Potentiates the Chondrotoxicity of Methylprednisolone (see this link), may be of relevance.
Not infrequently we'll see patients in whom the first or second injection helped, but from #3 on, there was no appreciable benefit. Occasionally we see shoulders that have had multiple injections and changes in the shoulder radiographs that are not typical of osteoarthritis. This is not intended to imply a cause/effect relationship.

Here's a recent example.

A very active young man sustained a hard fall on his shoulder. He received a series of intra articular injections as he documented for us here:

His current shoulder radiographs are shown here:

While this use of injections is common practice, we were struck by the cystic changes in the bone on both sides of the joint - changes that are not typical of post-traumatic arthritis in our experience. It is surely not possible to know if there was an association between these changes and the injections.

For comparison, the x-rays below show the more typical appearance of osteoarthritis.

Here are some quotes from the American Academy of Orthopaedic Surgeons 2013 guidelines (see this link) regarding the use of injections for arthritis of the knee:

Procedural Treatments: Recommendations 8-11
RECOMMENDATION 8
We are unable to recommend for or against the use of intraarticular (IA) corticosteroids for patients with symptomatic osteoarthritis of the knee.
Strength of Recommendation: Inconclusive
Description: Evidence from a single low quality study or conflicting findings that do not allow a recommendation for or against the intervention. An Inconclusive recommendation means that there is a lack of compelling evidence that has resulted in an unclear balance between benefits and potential harm.
Implications: Practitioners should feel little constraint in following a recommendation labeled as Inconclusive, exercise clinical judgment, and be alert for emerging evidence that clarifies or helps to determine the balance between benefits and potential harm. Patient preference should have a substantial influencing role.

RECOMMENDATION 9
We cannot recommend using hyaluronic acid for patients with symptomatic osteoarthritis of the knee.
Strength of Recommendation: Strong
Description: Evidence is based on two or more “High” strength studies with consistent findings for recommending for or against the intervention. A Strong recommendation means that the quality of the supportingevidenceishigh. Aharmsanalysisonthisrecommendationwasnotperformed.
Implications: Practitioners should follow a Strong recommendation unless a clear and compelling rationale for an alternative approach is present.

RECOMMENDATION 10
We are unable to recommend for or against growth factor injections and/or platelet rich plasma for patients with symptomatic osteoarthritis of the knee.
Strength of Recommendation: Inconclusive
Description: Evidence from a single low quality study or conflicting findings that do not allow a recommendation for or against the intervention. An Inconclusive recommendation means that there is a lack of compelling evidence that has resulted in an unclear balance between benefits and potential harm.
Implications: Practitioners should feel little constraint in following a recommendation labeled as Inconclusive, exercise clinical judgment, and be alert for emerging evidence that clarifies or helps to determine the balance between benefits and potential harm. Patient preference should have a substantial influencing role. 

Here is an interesting recent post about platelet rich plasma (see this link).

The bottom line is that we do not know (1) how injections affect the natural history of shoulder arthritis or (2) what regimen of injections is likely to maximize safety and efficacy.

The patients we most commonly see in our office have advanced arthritis with virtually complete loss of the cartilage over the glenoid and humeral head. In such cases it seems unlikely that injections will change the subsequent course of the disease.

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Shoulder injection led to shoulder infection

We were recently consulted by a man in his 40s who had a painful shoulder after a motor vehicle accident in the past. A year and a half ago he had these x-rays and limited motion of his shoulder.

A year ago he had an injection into his shoulder, after which his shoulder pain increased dramatically. He then underwent an arthroscopic washout for a shoulder joint infection that he thinks may have been due to staphylococcus.

He then presented to us with a completely stiff shoulder and these x-rays.

We plan a debridement with cultures, a primary hemiarthroplasty and intravenous Vancomycin and Ceftriaxone.

Comment: We do not know the degree of sterile precautions that were taken at the time of his injection. In any event, this case demonstrates that shoulder injection is not without risk.

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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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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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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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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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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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Steroid injection - what's in the bottle? "Can't you just give me a cortisone injection, doc?"

In Vitro Cytotoxic Effects of Benzalkonium Chloride in Corticosteroid Injection Suspension


Patients often ask for an injection of their shoulder to relieve pain or to get them ready for some special event. We've never been a big fan of the use of intraarticular steroids because of a concern of the potential risk of tendon and cartilage degeneration.

The authors of this article point to another possible risk: that due to preservatives in the bottle.

They treated human and bovine articular chondrocytes, bovine synovial cells, mouse C3H10T1/2 cells, and human osteosarcoma MG-63 cells were treated for thirty minutes in monolayer or suspension culture with an injectable corticosteroid suspension or its chemical components, including betamethasone sodium phosphate, betamethasone acetate, and benzalkonium chloride (as preservative). 

They found that the injectable corticosteroid suspension caused death in in vitro culture of human and bovine articular chondrocytes as well as bovine synovial cells because of its preservative benzalkonium chloride. The betamethasone corticosteroids per se did not cause significant chondrocyte death under the conditions tested.

We need to read the bottle and be sure we're comfortable with what we're injecting.

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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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