From the Guidelines
Administering shoulder cortisone injections without imaging guidance is not recommended due to the significant risks of needle misplacement, potential damage to nearby neurovascular structures, and reduced effectiveness. The primary risks include injection into incorrect structures, potential damage to nearby neurovascular structures, reduced effectiveness due to imprecise medication delivery, and possible complications such as tendon rupture or infection. Without imaging guidance such as ultrasound or fluoroscopy, the accuracy of injection placement decreases substantially, particularly in complex shoulder anatomy where the subacromial space, glenohumeral joint, or acromioclavicular joint may be targeted. Typical cortisone preparations used include methylprednisolone (40-80mg), triamcinolone (20-40mg), or betamethasone (6-12mg), often mixed with 2-5ml of lidocaine 1% for immediate pain relief. According to the most recent guideline 1, imaging guidance is conditionally recommended for use with intra-articular glucocorticoid injections of joints that are difficult to access, such as the shoulder. The American College of Radiology also recommends the use of MRI or ultrasound for evaluating shoulder pain when radiographs are noncontributory 1. While blind injections may be appropriate for straightforward cases with clear landmarks and experienced providers, imaging guidance becomes increasingly important for patients with obesity, anatomical variations, previous shoulder surgery, or when precise targeting is critical for therapeutic success. The risk-benefit assessment should consider these factors alongside resource availability and cost considerations when determining the appropriate approach for shoulder cortisone injections. Key considerations for the use of imaging guidance include:
- The skill of the practitioner
- Availability of imaging
- Costs
- Risk of delay in treatment 1 In terms of specific imaging modalities, both ultrasound and fluoroscopy are recommended for guiding intra-articular glucocorticoid injections 1. Ultimately, the decision to use imaging guidance for shoulder cortisone injections should be based on a careful evaluation of the individual patient's needs and circumstances, with a focus on minimizing risks and optimizing outcomes.
From the FDA Drug Label
Unless a deep intramuscular injection is given, local atrophy is likely to occur. (For recommendations on injection techniques, see DOSAGE AND ADMINISTRATION.) Due to the significantly higher incidence of local atrophy when the material is injected into the deltoid area, this injection site should be avoided in favor of the gluteal area.
The administration of shoulder cortisone injection without imaging may lead to local atrophy if the injection is not given deeply into the muscle. The deltoid area, a common site for shoulder injections, has a higher incidence of local atrophy and should be avoided if possible. Key points to consider:
- Local atrophy is a potential risk of cortisone injections
- Deep intramuscular injection is recommended to minimize this risk
- The deltoid area should be avoided due to the higher incidence of local atrophy 2
From the Research
Risks of Administering Shoulder Cortisone Injection without Imaging
- The risks of administering shoulder cortisone injection without imaging are not directly addressed in the provided studies, but the importance of image guidance in corticosteroid injections can be inferred from the studies 3, 4, 5.
- A study comparing image-guided versus blind corticosteroid injections found that image-guided injections had statistically significant greater improvement in shoulder pain and function at 6 weeks after injection 4.
- However, a systematic review found that ultrasound-guided injection probably provides little or no clinically important benefits compared with injection without guidance with respect to pain or function at three to six weeks follow-up 5.
- Another study found that patients who received manual physical therapy had less shoulder impingement syndrome-related health care use than those who received corticosteroid injections 6.
- A post hoc analysis of a randomized controlled trial found that elasticity of the long head of the biceps brachii tendons and supraspinatus tendons is unlikely to change after a single dose of peritendinous or intrabursal corticosteroid injections 7.
Potential Complications
- Transient pain from the corticosteroid injection was reported as an adverse event in one study 6.
- Another study found that patients who received corticosteroid injections had more shoulder impingement syndrome-related visits to their primary care provider and required additional steroid injections 6.
- The provided studies do not mention any serious adverse events related to corticosteroid injections without imaging.