shoulder injection

What are the different types of injections for shoulder pain?Shoulder Injection


When looking at injections around the shoulder, there really are multiple areas which may be causing discomfort.


Shoulder pain may be coming from:


  • Shoulder Joint itself where the ball meets the socket, called the glenohumeral joint.
    • Joint arthritis – osteoarthritis or post-traumatic
    • Cartilage tear – this is called a labral tear
  • Subacromial space, which is the  area above the shoulder joint near the rotator cuff region.
    • Rotator Cuff Tear or Tendonitis
    • Impingement Syndrome (bursitis)
  • Acromio-clavicular joint – the joint where the clavicle meets up with one of the shoulder bones.
  • Soft Tissuesaround the shoulder may have inflammation including:
    • Biceps tendonitis
    • Deltoid related pain
    • Frozen Shoulder (adhesive capsulitis)


How does the pain management doctor know what kind of shoulder injection to perform?


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The answer to this is by knowing what is causing the patient’s pain. This requires a comprehensive history and physical examination along with any imaging studies necessary to figure out a diagnosis.


As you can see in the picture to the right, there are quite a few anatomic areas in and around the joint that can benefit from an injection.


For instance, if a person is having a lot of tenderness over the acromio-clavicular joint then it may be an AC joint arthritis problem. If the person has had a previous AC separation there may be residual pain.


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Impingement Syndrome (Rotator Cuff Tendonitis)


If an individual has significant pain lifting their arm forward and pain with other physical examination maneuvers, it may be Impingement Syndrome, also known as Rotator Cuff Tendonitis.


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Notice the Swollen Bursa and the Inflamed Rotator Cuff Tendon

The most common shoulder problem by far in America is impingement syndrome. This is where a soft tissue above the shoulder joint gets inflamed and causes pain. This is called bursitis. The bursa is a soft tissue protective covering that overlies and protects soft tissue areas, in this case it’s the rotator cuff muscle.


This problem affects millions of individuals in the US, and over 95% of the time will not require surgery.


Impingement syndrome is also referred to as rotator cuff tendonitis (used interchangeably), and results from the soft tissues rubbing up against the bone of the shoulder called the acromion as a person lifts his or her arm. The bursa or underlying rotator cuff may become inflamed.


Initial treatment consists of oral NSAIDS and physical therapy, and a pain doctor can perform a steroid injection into the space underneath the acromion called the subacromial space. This is called a subacromial injection and may be performed every few months if it is providing relief. This injection may be done in an office setting without fluoroscopy as it is not hard to accurately find the space using landmarks on the skin.


One type of injection that may be performed for diagnostic purposes is one with numbing medicine only in the office to see if it provides immediate relief with arm movement. If it does, the diagnosis is confirmed for impingement syndrome and a follow up steroid injection should give longer term relief of weeks to months.


Glenohumeral Joint Injection


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A subacromial injection is done in an office setting. It may diagnose impingement syndrome and also provide pain relief for months.

If the person has arthritis in the shoulder joint itself, called the glenohumeral joint, then total shoulder replacement is a successful procedure as a last resort. Patients may get months to years of pain relief nonoperatively with anti-inflammatory medications, physical therapy and chiropractic treatment, and steroid injections into the joint (van der Windt BMJ 1998).


These injections may be repeated every few months typically with excellent results.
Whether or not there are deleterious effects of steroids to the joint cartilage over multiple injections has not been definitively shown. The benefits of steroid joint injections outweigh the risks.


Hyaluronic Acid Injections


The newest type of injection into the shoulder joint is hyaluronic acid formulations. This includes such brand names as Synvisc, Orthovisc, Supartz, and others. They have been shown to provide months of pain relief and theoretically will help promote cartilage formation. Cartilage formation has been shown in animal studies but is only theoretical in humans.


The pain relief achieved, however, is real and has been shown to be a successful injection for chronic shoulder pain due to arthritis (Leardini, Clin Ther 1988). Pain relief may last for over 6 months, and these injections are performed as a series of 3 to 5 injections, one to two weeks apart.


If the person is having tenderness and pain over the acromio-clavicular joint, commonly called the AC joint, an injection into the joint may be of tremendous benefit. This pain may be a posttraumatic situation where the person had an AC separation previously or may simply be due to wear and tear arthritis. Either way, steroid injections into the AC joint are typically very helpful and also may be repeated every few months.


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Additional soft tissue injections that can be of benefit are for tendonitis of the biceps or for frozen shoulder. Frozen shoulder represents a stiffening of the tissue around the joint, called the joint capsule. Steroid injections into the joint and soft tissues may make it possible to achieve some pain relief and increase shoulder range of motion.


What are the Outcomes of Shoulder Injections?


Steroid injections for shoulder problems have a long history in orthopedics and pain management treatment. With shoulder arthritis resulting in a quality of life situation similar to knee and hip arthritis, the objective is to avoid or delay surgery if at all possible.


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Steroid injections have been shown to have excellent results in treating osteoarthritis of the shoulder. A 2009 study in the Archives of Physical Medicine confirmed the beneficial effects for Frozen Shoulder and a 2005 study in the British Journal of General Practice showed excellent results for subacromial injections for treating tendonitis.


Injections in and around the shoulder joint have variable lengths of action. They may last for days, or they may last for months.


What are the Risks of Shoulder Injections?


The risks of shoulder injections are mainly due to the steroid substance utilized. There is a small risk of infection, bleeding, with the biggest risk being failure to achieve pain relief. Temporarily a person may have a blood sugar elevation, water retention, or slight weight gain. These effects typically go away within a few days.


There was a study presented at the 1999 American Academy of Orthopedic Surgeons showing that repetitive steroid injections into the subacromial space may affect the quality of the surgical repair if rotator cuff repair is subsequently performed.  The amount of injections appropriate is unknown. What is known is that injections work very well in moderation for both soft tissue inflammatory problems along with arthritis.Arizona Pain Specialists


The pain management doctors are Board Certified and Fellowship Trained, serving Phoenix, Glendale, Chandler, Scottsdale, Mesa, Surprise, Tempe, Gilbert, and more.


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