For most shoulder & elbow surgeons a “ shoulder steroid injection” means a combined single injection of steroid and local anaesthetic. There are two commonly used steroids for musculoskeletal injections in the UK; methylprednisolone (Depo-medrol) and triamcinolone (Kenalog). I prefer to use triamcinolone in my injections as it tends to have a longer lasting effect. The local anaesthetic used in combination with the steroid depends on the area being injected. I tend to use low concentrations of local anaesthetic when injecting the glenohumeral (shoulder) joint in order to protect the articular cartilage.
What are steroid injections used for in the shoulder or elbow?
The use of steroids around any joint should be limited to the control of pain through reducing inflammation. Sometimes steroid injections can be used to treat conditions (therapeutic) or can help to confirm the source of pain in or around the shoulder (diagnostic), most of the time they do both.
Around the shoulder there are 4 conditions that I commonly recommend steroid injections for; frozen shoulder, acromioclavicular joint (ACJ) degeneration, subacromial shoulder pain, and tenosynovitis of the long head of biceps (LHB) tendon. For subacromial pain steroids are used to help control pain in order to allow the patient to do their physiotherapy exercises which is the key treatment for this condition. I give most steroid injection in the clinic after consultation and confirmation of the diagnosis, however, LHB injections are best performed under ultrasound guidance.
Around the elbow I very rarely use steroid injections. Steroid injections used to be commonly used to treat tennis elbow, but we now know from several research studies that steroid injections can give good pain relief for about 6 weeks, however pain can return, and patients can be worse off than if they had no treatment at all. I do not recommend steroid injections for tennis elbow.
How painful is a steroid injection and can I drive afterwards?
Steroid injections will sting for about a minute and most patients don’t find them that painful in and around the shoulder. It is the local anaesthetic component that causes the stinging sensation. Once the stinging goes away, the local anaesthetic pain-relieving effect kicks in so that patients often have rapid pain relief. It is safe to drive after a steroid injection around the shoulder.
How long do steroid injections last?
The local anaesthetic effect of the injection wears off after a few hours and pain will recur. Steroids themselves take about 2-3 days to kick in so there is usually a gradual reduction in symptoms in the early days following a steroid injection. The duration of the effect of steroids is difficult to predict. Some injections may last weeks or months while others only last days. It is a common observation that the more steroid injections you have the less effective and shorter their duration is.
What are the most common steroid injection side effects?
The most commonly observed side effect of a steroid injection into a joint is steroid flare where the joint becomes painful and irritated by the injection. Other rarer side effects include skin or fat atrophy (scarring), depigmentation, and VERY rarely but importantly steroid injections can cause joint infection.
In diabetics, steroid injections can cause a rise in blood glucose readings which can last for a couple weeks after the injection.
Are there extra risks of steroid injections during the COVID-19 Pandemic?
There is some evidence that steroids can increase the risk of viral infections by suppressing your immune system. There aren’t any research studies about the risk of steroid injections and COVID-19 but as this is a new virus we are advising caution. Patients who are over 70 or have medical conditions such as diabetes mellitus, ischemic heart disease, chronic respiratory disease, and hypertension may be at higher risk from COVID-19 so they need to take extra caution. Patients in the shielding group should avoid steroid injections due to their possible risk and the risk of a hospital visit to get the injection. Patients should try alternative treatments such as anti-inflammatory drugs, and icing to control inflammation and pain.
Before considering a steroid injection patients will need to read this blog, and sign a consent form stating that they understand the risks. The British Orthopaedic Association, British Elbow & Shoulder Society and British Society of Surgery of the Hand have created a useful patient information leaflet for upper limb steroid injections. View the patient information leaflet and consent form here.
Patients are advised to continue to use hand washing, social distancing and face coverings where appropriate to reduce their risk of contracting COVID-19.
Should I delay my steroid injection if I have had the COVID-19 vaccine?
Current guidance suggests that if you have had the COVID-19 vaccine you should delay any steroid injections until at least 2 weeks after you vaccine. This is currently a precaution to ensure that the steroid doesn’t suppress your immune response to the vaccine.
What if I’m needle phobic?
Good news: I do my steroid injections from the back or the top of the shoulder with the head turned away, so you NEVER have to see the needle and the injections are quick and last only seconds.
Can I have more than one steroid injection?
As said before repeated steroid injections tend to have a diminishing effect and like playing the lottery, increasing the number of injections increases your risk of getting a complication.
If a steroid injection hasn’t worked, we should consider if the diagnosis is correct. If the injection has worked but pain recurs, then we should consider progressing to the definitive treatment for the condition.
There are some conditions or circumstances where multiple steroid injections may be required, particularly for patients that are not fit for surgery, and in these cases I recommend maximising the time between injections so that not more than two or three injections are given in a year.
If you have any of the conditions above or need a steroid injection please get in touch and book an appointment.