The shoulder is a complex joint that relies on many muscles, tendons and ligaments to hold it together. The shoulder can develop a multitude of conditions. Common ailments that can occur are tendinitis, bursitis, rotator cuff syndrome, frozen shoulder (also known as adhesive capsulitis) and degenerative or inflammatory arthritis. Inevitably, all of these conditions will develop varying degrees of pain, inflammation and stiffness. Unfortunately, these conditions are often a challenge to treat due to the usage of our shoulder joint in all aspects of work and recreation.
All therapy is aimed at reducing pain and inflammation and restoring ranges of motion and functionality. Usually, conservative care is initially prescribed. But, if results are not satisfactory after an appropriate course of conservative care, more invasive medical intervention may be considered. There are varying degrees of “invasiveness” which would tend to range from injection therapy to surgery.
The most common form of injection therapy involves the use of corticosteroids, or just “steroids”. These are synthetic drugs that resemble cortisol, a hormone that you produce in your adrenal glands. Note that steroid injections are not the same as the enhancement drugs that some athletes have used. Corticosteroids have an anti-inflammatory affect and may be given orally. But injections allow for an increased dosage to a specific area of the body. Also, local injection may help avoid the need for oral steroids which could have greater side effects such as stomach irritation.
Steroid injections are readily available and can be administered at your doctor’s or specialist’s office and can often give immediate relief of a local area. This is welcoming when one has suffered with pain for a long period of time. But, as with any therapy, steroid injections may or may not be effective.
What to Expect
When getting an injection, the doctor, nurse of other health practitioner will swab the area with alcohol or iodine-based cleaning solution. They may utilize a numbing lotion or spray over the site or the steroid may be mixed with an anaesthetic solution. There may be slight burning or pressure with the injection. Occasionally, the injection will be administered with the use of ultrasound imaging or a special motion x-ray called fluoroscopy. This allows the practitioner to visualize the tissue on a monitor in order to allow for a more precise injection procedure. After the shot, a bandage will be applied. In the case of injecting a joint, if the joint has too much fluid, the excess may be drawn out using a separate syringe.
The anaesthetic usually wears off after a few hours. After the injection some people experience pain for 24-48 hours – this is known as post-steroidal flare. Ice or over-the-counter medication may be used to relieve this discomfort. You can usually resume full function after you have an injection but your doctor may tell you to avoid strenuous activity for approximately 2 weeks. Some people have a warm feeling in their face and chest after a shot. If you are diabetic, you may have a temporary increase in your blood sugar levels. The corticosteroid usually takes approximately 1-2 days for you to feel its effects with reduced inflammation and decreased pain.
Injection Side Effects
As with any medication, there are possible side effects or risks involved. Common risks from steroid injections include pain at the injection site, bruising due to broken blood vessels, skin discolouration and aggravation of inflammation. Rarer risks include allergic reactions, infection, tendon rupture and serious injury to bones called necrosis. Long term side effects (depending on frequency and dose) include thinning of skin, easy bruising, weight gain, puffiness in the face, higher blood pressure, cataract formation, and osteoporosis (reduced bone density). Steroid injections may be given every 3-4 months but frequent injections may lead to tissue weakening at the injection site and is not recommended. Side effects do not happen in everyone and vary from person to person.
A recent study in the Annals of Internal Medicine, August 2014, compared a one year outcome of steroid injection to physical therapy for shoulder impingement syndrome. Both groups showed the same pain level and disability improvement after 1 year (approximately 50% improvement). But 60% of the injection group had to return to their primary care doctor after 1 year as compared to 37% of the physical therapy group. Also, the injection group were more likely to need more injections or physical therapy after 1 year.
If you happen to be from Ontario, Canada, application of the injection is covered under OHIP (in Ontario) but you must purchase the medication from the pharmacy. This may be covered under private health insurance or the Ontario Drug Benefit Program. Other Canadian provinces will likely have similar benefits.
In conclusion, with any shoulder condition it is best to start a trial of conservative care. If after a reasonable period, this does not prove effective, imaging and further medical intervention should be considered. Steroid injection is a widely used and relatively safe option but, as with any therapy, should be utilized with care.