What about an injection?

What about an injection?

One of the most common questions I get with shoulder injuries is whether a corticosteroid injection will help. My answer is: Maybe. But it depends what you’re looking for: Pain? Perhaps. Function? Hopefully. Tendon Integrity? Unlikely. So why is it prescribed so much? Is it the general population’s shift towards passive and immediate pain relief with little active component? We’ll dive into some of the current literature.

Rotator cuff tendinopathies encompass a wide range of conditions including impingement, rotator cuff fraying, partial thickness tears and tendonitis. Lately, common practice has been to provide a corticosteroid injection to relieve symptoms associated with rotator cuff tendinopathy, however the effectiveness is widely debated.

Whenever a client comes to me with significant shoulder pain I generally go over 3 treatment options: 1) conservative care, 2) semi-invasive procedures such as an injection and 3) surgery. We’ve addressed our conservative care approach to rotator cuff tendinopathies in our previous blog posts. Therefore, in this blog we will look at the effectiveness of a corticosteroid injection for treatment of a rotator cuff tendinopathy.

A recent meta-analysis addressed 3 important questions:

  1. Do injections help reduce pain 3 months post?
  • Corticosteroid injections only had a small transient pain relief 1-2 months post injection as compared to a placebo injection. However, there was no difference at the 3-month re-assessment in adult patients with rotator cuff tendinopathy.
  1. What are the odds an injection will help?
  • For every 5 patients treated with a corticosteroid injection, only 1 would experience a slight transient reduction in pain.
  1. Are multiple injections better than a single injection?
  • Multiple injections were not found to be more effective than a single injection at any time.

It’s important to note that corticosteroid injections did not modify the natural course of the disease. Rather, studies have shown that injections can actually accelerate tendon degeneration resulting in collagen disorganization, decreased loading capacity, long term harm to the tendon tissue and cells and possibly spontaneous rupture. A study on rats demonstrated that repeated doses of corticosteroids significantly weakened rat rotator cuffs, negatively affected bone quality and may deteriorate tendon to bone insertion sites.

In conclusion, there is little reproducible evidence to support the use of sub-acromial corticosteroid injections for rotator cuff tendinopathies. The authors attributed this to physician habits, under-appreciation of the placebo affects, a tendency to satisfy rather than discuss alternative options and society’s push towards a passive, “quick fix” mentality.

Ultimately, it is a short-term plan for a long-term problem. Rotator cuff tendinopathies can take anywhere from 3 months to over a year to heal.

So as a patient, know your options. An injection seems desirable, but given the above information may not be the best long-term option for you. Try conservative care first. Stick with it; it is a long haul, but your tendon will thank you later.

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