I hear questions and concerns, very often, about cortisone shots for shoulder pain. Many patients want to know if it is safe. Others, simply are adamantly against it. So, what is the truth?
The fact of the matter is that the effects of cortisone injections upon a tendon is not fully understood. Some orthopedic surgeons use them very liberally while others limit its use. The unwritten rule has typically been no more than 2 shots per year per joint. But, is that really an accurate assessment?
The most common reason for a cortisone shot in the shoulder is Rotator Cuff disease or Rotator Cuff Impingement. This is the process where the rotator cuff tendons are pinched and damaged by a bone spur digging in to the tendon from the bone above. This can be very painful and may often lead to a full rotator cuff tear. Typically, the initial treatment is physical therapy. If the physical therapy does not resolve the pain then further options include a cortisone shot ( to diminish inflammation and pain) or, minimally invasive Shoulder Arthroscopic surgery (to remove the inciting bone spur).
Many patients are reserved about the cortisone shot and elect to proceed to arthroscopic surgery when physical therapy does not help. In some ways these patients' concerns are completely validated. A study in 2006, in the American Journal of Bone & Joint Surgery, concluded that a single cortisone injection, during the acute phase of injury to the rotator cuff, does not alter the collagen. Nonetheless, the same dose of steroid to an uninjured rotator cuff tendon causes a response, in the rotator cuff, that is equivalent to structural injury to the collagen. The conclusion was that, while one cortisone injection may have no long-term effects, a single injection does alter the collagen composition acutely and caution should be applied in the immediate period after the injection.
In 2009, a study in the Annals of Royal College of Surgeon of England, concluded that a cortisone injection for rotator cuff impingement should not be considered a cause for an eventual rotator cuff tear. Another study in 2009 found that steroid injections are more effective for the short term but the effects are similar to anti-inflammatory medications (such as Ibuprofen, etc). Most recently, in July of 2015, a study from Israel, on this topic, was published in the American Journal of Sports Medicine. Their conclusion was that repeated doses of cortisone injections weaken the rotator cuff tendons, as well as weakening the bone quality and possibly causing deterioration of the connection between the tendons and bone. This was an animal study, and clinical studies need to be further investigated, but it does amplify the fact that both benefits and damaging effects should be considered before a cortisone injection.
In my experience, younger and active patients, that do not improve with physical therapy, most often forgo the cortisone shot and prefer to definitively cure the problem with Shoulder Arthroscopy. Older and less active patients, frequently, benefit from trying the cortisone injection and, if it helps, may have another the following year. More information is still needed but our views of cortisone injections in the shoulder is constantly evolving.
- Leon E. Popovitz, MD