Steroid Injections

The dreaded steroid injection. What a controversial topic this is though it really shouldn’t be and lets see if I can put the record straight.

Steroids do have a bad name and quite rightly so if they are misused and you will all have heard about steroid abuse in athletes and body-builders for example. I am more concerned about a different sort of abuse – where doctors treat painful shoulders with injection after injection after injection failing to realise or accept that there is a structural issue and that surgery may actually be the right thing to offer. Sadly I’m afraid this comes down to a little bit of professional rivalry but thankfully I see the situation where a patient only gets to me after 8 or more injections less and less frequently.

Won’t the injection just mask the symptoms not cure them?

It may do and you may have a pain-free shoulder just for a few weeks. But that’s when the important next decision needs to be made. If the steroid hasn’t cured your shoulder then there is probably very little point in repeating the injection because the chances are that the same thing will happen – good for a few weeks then painful again.

So you only do one injection? Someone said you should only have 3.

I generally only do one injection and if that does the trick i.e. you are pain free and doing all your sports and activities with no recurrence of the pain after about 6 weeks or so, then I would consider you cured. I usually recommend therapy during that pain-free window to help get rid of any bad habits in the way you use your shoulder as well.

Then what?

Then an operation. Usually I do a steroid injection for tendonitis/Impingement/Rotator Cuff Syndrome and will have done x-rays or a scan to get an idea of the structural state of your shoulder and if there are spurs or hooks on the acromion or calcific deposits in the tendon or arthritis in the AC joint then an operation should be considered.

My shoulder was only pain-free for a week though. Mind you it was lovely for that week and I really though you had cracked it. If that injection didn’t work why would an operation?

Actually I would say that injection did work. Okay it didn’t work for very long but you were back to normal if only for a week and that tells me that your shoulder is definitely cureable and that I can get the same result on a permanent basis with surgery.

I can’t take the time off for an operation now. Could I have another injection to get me through till I can?

That is a reasonable request and something I do do quite frequently. If you had a good 6 weeks or so after the first injection but now it is painful again and the timing is not right for surgery then I can buy you a bit more time with a second injection.

My GP did an injection but it made no difference and I’m not keen on another one.

That is understandable but, at the risk of upsetting all my GP colleagues, they aren’t always doing the injection the best way. Remember I do shoulder injections many times a week whereas the GP will be doing them only occasionally. Many of them also still use a rather out-dated technique which we now know isn’t so effective. So I tend to ignore a failed injection from a GP and start afresh.

This is my first steroid injection. Is it going to hurt?

I am afraid so because it is a needle but, usually, it is not a big deal and frequently what patients say is “was that it?”. That isn’t always the case though and it can be painful at the time.

Can I use my arm afterwards?

Straight afterwards things are often fine and, indeed, you may find that the pain goes away instantly because of the local anaesthetic I use. So you can drive home from the clinic and do normal things with your arm.

In about 25% of cases the shoulder can be a lot more painful the next day and can be bad for a few days. You just need to take pain-killers and grin and bear it because it will pass and then, hopefully, you will find that your shoulder pain has settled.

When I can I get back to sports?

Always remember that it is often your sport that has contributed towards your pain – especially overhead activities like tennis and swimming and weights in the gym. So, if the injection gets you pain free do not rush back into those activities but use the pain-free window to work with a therapist to regain control of the shoulder, get rid of any bad habits and work on strengthening the important muscle groups before venturing back to sports.

Why are you injecting the back of my shoulder when all the pain is in the front? In fact, why are you injecting my shoulder at all when all the pain is down my arm?

The pain you get in your arm is called “referred pain” and is actually generated in the shoulder but appears in the front or side of the upper arm. Before I do the injection I will have put your shoulder through a series of manoeuvres and tests and that should have demonstrated to you that moving the shoulder causes the pain down the arm.

And the reason I inject through the back is that it gives the best access to the whole sub-acromial space – the area above the rotator cuff and below the bone that the tendon has been rubbing on. It’s the same place I put the arthroscopic camera into your shoulder if it comes to surgery, so I know the needle is in the right place.

And what exactly do you inject?

I use a mixture of 0.5% Chirocaine which is a local anaesthetic that has two roles. It helps to numb the shoulder (which explains why sometimes your pain can go pretty much straight away) and it increases the volume of the injection to 10mls which helps spread the steroid across the whole of the tendon area. The steroid I use is called Depomedrone and I use 80 mg. That is only 2mls in volume and given by itself could just disappear into the fat or other tissues unless it is absolutely in the exact spot and that’s why I add the local anaesthetic – to get a bigger volume which is much more effective.

I am on Warfarin so can’t have an injection.

Well, actually you can and I don’t worry about the blood thinners unless your control is very poor.

I am massively needle phobic and there is no way I am having an injection.

You are not alone and what I can do is admit you to the hospital for half a day; get you down to theatre where the anaesthetist can sedate you (without using a needle!) and then I can do the injection without you knowing anything about it. So don’t worry about that.

Many people do have worries about a steroid injection: perhaps because they have heard bad things about them; or don’t think they can be a cure; or don’t want ‘artificial’ products in their system; or have had one before that made no difference. I hope I have shown that these worries are not based on the actual facts and really their only worry is if someone is treating them with multiple injections.

An injection does hurt (a bit) but as you must have been in pain anyway if you have come to see me, that would seem a small price to pay for a treatment that, much more often that not, will make you better and may be all you need to get back to normal.