These treatments make up a very important part of the management of shoulder injuries. In combination with an active rehabilitation program. They can reduce the need for surgery in shoulder impingement syndrome.
Cortisone or steroid injections provide a potent anti-inflammaton. Discovered as recently as 1950. And has been available in an injectable form since 1951. It acts on both acute and chronic phases of inflammation. Reducing both tissue swelling and scar formation.
Cortisone joint injections are useful in the treatment of various musculoskeletal conditions. Particularly those of acute inflammation, and degenerative joint and tendon conditions.
In the shoulder, they are particularly useful in the management of:
Rotator cuff disease (degenerative tendinosis, impingement, partial tears, and subacromial bursitis)
Adhesive capsulitis (or ‘frozen shoulder)
Acromioclavicular joint disease (osteoarthritis or osteolysis)
Cortisone injections should only be performed in the setting of an appropriate diagnosis. Based on taking an accurate history. Performing a clinical examination and commonly performing investigations. They will generally be used after failure of a 4-6 week trial of relative rest. Anti-inflammatory modalities and medications and an exercise-based physiotherapy program.
Common Misconceptions & FAQ’s
Cortisone injections are painful.
The majority of patients expect the injection to be very painful. Most are pleasantly surprised that it isn’t the case. At the time of injection, it should hurt no more than a common immunization needle. Around 1:20 patients may have pain that is worse after the injection. This generally occurs for no more than 2-3 days. It is related to irritation of the tissue injected from the cortisone itself. This ‘injection flare’ is much less common. As modern cortisone injections are more water-soluble. Treated with local ice packs and simple analgesics.
You should only have 3 injections.
There is no scientific evidence to support this statement. Common sense would suggest if 3 injections given at 8-12 week intervals have not helped, then further injections are not likely to be beneficial.
Cortisone injections will make me fat and give me weak bones.
Taking oral cortisone (or prednisone) for long periods of time can have side effects. These would include weight gain, osteoporosis, diabetes, and high blood pressure. A small amount of cortisone is absorbed after an injection, but quickly cleared within 2-3 days. There are no long term side-effects from repeat local injections of cortisone.
Isn’t this injection just a painkiller?.
The cortisone injection is not just an analgesic or painkiller. It works by reducing inflammation, and thus pain. As such it is treating the pathology, not just the pain. It is important that the injection is followed up with appropriate rehabilitation.
Side Effects – Local cortisone injections may cause some side effects.
These would include:
Systemic absorption. Care should be taken in diabetics as blood sugar levels may rise
Infection – The medical literature suggests this occurs in less than 1:20,000 cases. It can be avoided by using a sterile ‘no touch’ technique with the needle and an alcohol swab
Crystal flare – As previously mentioned occurs in 1:20 patients. It can be treated with ice and paracetamol
Skin changes – Skin atrophy & pigment loss may occur around the injection site. This is generally a minor cosmetic problem and occurs in less than 1:100 patients
Bleeding (especially if the patient has a bleeding tendency)
Neuritis – The cortisone may cause minor irritation to nerves if injected around them
FAILURE OF CORTISONE INJECTIONS
Cortisone injections make up an important part of the treatment of various shoulder conditions. They are, however, not the only method of treatment, but part of a management program. The cortisone injections do not cure the condition. But provide a window of symptom relief via inflammation reduction. This then allows pain-free rehabilitation exercises to be performed. Improving joint motion and muscle strength and function. Which will hopefully prevent the condition from recurring later on. All cortisone injections should ideally be followed up with a physiotherapy program. Including manual therapy and exercise-based rehabilitation.
Failure of cortisone injections may occur for various reasons. The most important factor to consider is an appropriate diagnosis. A rotator cuff injection will not help an acromioclavicular joint problem. Correct placement of the needle is also essential. In some cases, imaging support (such as an ultrasound) may be used to confirm the needle position. Inadequate follow-up rehabilitation and activity modification is another common reason for failure.
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