Shoulder Surgery
Shoulders, elbows, innovation

Steroid injections

Steroid injections around the Shoulder

This video shows an interactive model for shoulder injection practice. The accuracy of needle placement is confirmed by green lights. Glenohumeral and subacromial injections are demonstrated. Contact us if you are interested in attending an injection teaching session.

Summary

Steroid injections are a common way of treating shoulder conditions. This can also be controversial. After accurate diagnosis that may require imaging of the shoulder, injections should be administered, if appropriate, by a trained clinician. This sometimes require image (normally ultrasound) guidance.

Background

Steroids are a group of anti-inflammatory medications that can be taken by mouth or injected for local or systemic benefit. A local steroid injection is administered to reduce inflammation within an area. This should improve swelling and pain and thereby also improve function. It is often usual to use local anaesthetic at the same time for both diagnostic and therapeutic reasons. Steroids should start working within a couple of days and the benefit can last many months. Multiple injections at the same site can cause local problems such as fat atrophy, tendon degeneration etc, and the need should be carefully evaluated.

Indications & Administration

Several shoulder problems respond to local steroid injections. These have to be accurately placed into different synovial cavities of the joint that is involved by the specific problem. Some will require image guidance - these are outlined below

  1. Gleno-humeral injection (the true shoulder joint) - Appropriate for inflammatory arthritis such as rheumatoid arthritis. Less useful for osteoarthritis as this is a degenerative condition. It is used in frozen shoulders but there is controversy about this. Anterior or posterior routes can be used.
  2. Subacromial injections - Useful for impingement syndrome - the commonest shoulder disorder. Rotator cuff tears should be excluded before the injections. The accuracy in expert hands is about 75%. USS guidance improves accuracy.
  3. Acromio-clavicular injections - Useful for degenerate conditions of the AC joint. Can be repeated as the only other treatment is often surgical excision. Again USS improves accuracy.
  4. Biceps sheath injections - for the specific diagnosis of biceps tendonitis. USS guidance is essential to avoid intratendinous injections and localise to the sheath.

Potential Problems

Systemic problems are very rare as this is locally acting steroid. Some of the more soluble preparations may affect diabetic control. Active infections may also be masked. Steroid injections should be used with utmost caution in poorly controlled diabetics and in the presence of infection.

Although it is possible to have more serious problems such as affecting the body's hormones, bleeding problems, osteoporosis, avascular necrosis, cataracts etc, these are very rare.

Local effects are far more common. These include

  • Skin changes with depigmentetation and fat atrophy
  • Chondrolysis - there is evidence that these injections damage normal cartilage tissue in joints. As the local anaesthetic that is often combined can also damage cartilage it is hard to establish a causal model. Of not is the fact that surgery can cause this as well, often correlated to anaesthetic infusions in joints.
  • Tendon damage - Concern exists regarding potential damage to the rotator cuff from repeated corticosteroid injections into the subacromial space, although there is some evidence that this is not the case1 . There is good evidence that steroids can weaken tendon tissue2,3 a fact that should be kept in mind if surgery is being considered as this can lead to higher failure rates. Tendon damage occurs more easily in presence of a tear as the steroid molecules are in direct contact with the tendon cells. It seems logical to restrict the number of injections around tendons for this reason.
  • There are also serious but very rare problems that have been reported

Conclusions

Where used appropriately, local steroid injections can control symptoms in shoulder problems in up to two thirds of patients. It needs to be used cautiously and with appropriate knowledge and skill to avoid the potential problems that can result.

References

  1. Correlation between rotator cuff tears and repeated subacromial steroid injections: a case-controlled study. Bhatia M, Singh B, Nicolaou N, Ravikumar KJ. Ann R Coll Surg Engl. 2009 Jul;91(5):414-6. Epub 2009 Apr 30.

  2. Tempfer H, Gehwolf R, Lehner C, Wagner A, Mtsariashvili M, Bauer HC, Resch H, Tauber M. Effects of crystalline glucocorticoid triamcinolone acetonide on cultered human supraspinatus tendon cells. Acta Orthop. 2009 Jun;80(3):357-62.

  3. Wong MW, Lui WT, Fu SC, Lee KM. The effect of glucocorticoids on tendon cell viability in human tendon explants. Acta Orthop. 2009 Jun;80(3):363-7