Read This Before You Decide To Get A Cortisone Injection For Your Shoulder

10 Apr

Shoulder pain is one of the top reasons why patients visit a physiotherapy practice, right after neck and back pain. 6.9–34% of the entire population have shoulder pain and 21% of those are older than 70 years (1). Most people deal with shoulder pain by keeping it sedentary, however in order to heal the shoulder, we must move it or it may end up as frozen shoulder (2). Having shoulder pain can profoundly increase socio-economic burdens, as we commonly use our arms in our day-to-day and work life to some extent.

Shoulder pain could be from:

structural issues in rotator cuff/tendon/bursa/bone&joint
from functional aspects such as impingement symptoms, adhesive capsulitis
referred pain from visceral or adjacent organs

So, your shoulder is in pain, you don’t wanna move it, you don’t know what to do…You go to the your primary care physician, and you’re offered this corticosteroid injection that may translate into an instant fix…Take it right? There could be nothing worse than what you’re experiencing right now.

Let’s dive into what really goes on

Highlighted animal studies shows that steroids can:

degrade collagen
decrease fibroblast proliferation (wound healing)
increase inflammation and cytotoxicity (cause damage to cells)
interfere with the biomechanics of tendons

In humans tendon studies we see:

collagen degradation
fibroblast ageing
impaired collagen healing

which is far less than desirable when it comes to tendon recovery, right?

In professional sports setting, when a professional basketball player gets an injection before going out to play, there’s a trade off. There’s a reason why its not being used for rehab, because you’re just using it to get a relief for a short amount of time when you’re in acute pain in order to be able to continue to make $80,000 from that single basketball game as a professional basketball player.

There are serious negative effects when steroids are used. In general, it destroys joints over time

We see increased fracture rates when epidural injections are given (2). Basically it’s been taken out of all guidelines, except in abject acute pain. So if you say “absolutely abject pain”, can't do any movement based therapy, any movement based care, injections can sometimes help kick-start this process.

Thing is, these things aren't meant to be lived on! Injections are NOT the solution. In fact they inhibit the healing process substantially.

What Does the Research Say?

A total of 1025 patients with shoulder diseases from 2013-2019; 205 patients with steroid injections, 820 patients without injections were followed up for 50 months, mean age 59.4 years old.

Found that almost 10% of the people that received steroid injections ended up having a rotator cuff tear, when only about 1% that did not receive the injection ended up having a tear (1) —-> THAT is a BIG deal, and is something everybody should know before getting that shot.
Some previous studies showed that steroid injections within 6 months of surgery will increase the risk of revision surgery; a lot of it is explained by softening of the tendons by the injections
A 2014 paper by Remiraze, reported an incidence rate of 17% for full thickness tendon tears in patients receiving steroid injections at 12 weeks follow up —> 1 in 5 people getting that steroid injection are getting a tear (4).

In Conclusion

Steroid injections on the shoulder were associated with an increased risk of rotator cuff tear by 7.4 times with a mean time to onset 39 months compared to non injection, the incidence of tearing was elevated 3.25 times when having concurrent chronic liver disease, and 2.5 times with a smoking habit (1).

Therefore

Injections can provide short term pain relief on occasion, BUT it can provide long term challenges because you have such a greater risk for tearing that tendon. So, our goal is to use movement (which you’re gonna have to do one way or the other) to decrease the pain, to increase the functional ability, to give you the best “fix” long term that doesn't require all those side effects that you can expect with an injection.

Hope this helps.

Your friendly neighbourhood Physio

Tony

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