What are the risks of administering a shoulder corticosteroid (cortisone) injection without prior imaging?

From the Guidelines

Administering a shoulder cortisone injection without prior imaging is not recommended due to the significant risks of misdiagnosis, inaccurate injection placement, and potential complications. The American College of Rheumatology guideline for the treatment of juvenile idiopathic arthritis recommends imaging guidance for intraarticular glucocorticoid injections of joints that are difficult to access, such as the shoulder 1. This recommendation is based on the fact that imaging guidance, including ultrasound and/or fluoroscopy, can help to specifically localize the distribution of inflammation and ensure accurate placement of the injection 1. Without imaging, the clinician may misdiagnose the underlying condition, potentially injecting cortisone into an inappropriate location or treating a condition that won't respond to steroid therapy 1. Some of the potential risks of blind injections include inadvertent injection into blood vessels, nerves, or tendons, which can cause tissue damage, bleeding, or nerve injury. Additionally, if the patient has an undiagnosed infection in the area, a cortisone injection could worsen it significantly. The standard cortisone preparations used for shoulder injections include methylprednisolone (40-80mg), triamcinolone (20-40mg), or betamethasone (6-12mg), typically mixed with lidocaine for immediate pain relief. Key points to consider when deciding on imaging prior to a shoulder cortisone injection include:

• The potential for misdiagnosis and inaccurate injection placement without imaging
• The benefits of imaging guidance in ensuring accurate placement and reducing complications
• The potential risks of blind injections, including tissue damage, bleeding, and nerve injury
• The importance of considering the patient's individual needs and medical history when deciding on imaging prior to a shoulder cortisone injection.

From the Research

Risks of Administering Shoulder Cortisone Injection without Imaging

• The risks of administering a shoulder cortisone injection without imaging prior to the appointment are not directly addressed in the provided studies 2, 3, 4, 5, 6.
• However, the studies suggest that image-guided injections may provide little to no benefit over injections without imaging in terms of pain or function 3.
• One study found that ultrasound-guided injections had statistically significant greater improvement in shoulder pain and function at 6 weeks after injection compared to landmark-guided injections 4.
• Another study found that triamcinolone acetonide injections showed a larger decrease in pain on the VAS scores after injection compared to hyaluronic acid and NaCl injections in the first week after injection 5.
• A retrospective cohort study found that 26% of patients with a new episode of shoulder pain received a corticosteroid injection, and half of the patients received the injection in the first consultation 6.
• No serious adverse reactions were recorded by the general practitioner in the retrospective cohort study 6.

Potential Complications

• The studies do not provide direct evidence on the risks of administering a shoulder cortisone injection without imaging prior to the appointment.
• However, the use of imaging guidance may help to reduce the risk of adverse events, such as injection into the wrong location or damage to surrounding tissues 3, 4.
• The studies suggest that the use of corticosteroid injections for shoulder pain is generally safe, with no serious adverse reactions reported in the retrospective cohort study 6.

Imaging Guidance

• The use of imaging guidance, such as ultrasound, may provide some benefits in terms of accuracy and effectiveness of the injection 3, 4.
• However, the studies suggest that the benefits of imaging guidance may be limited, and that injections without imaging guidance may be effective in reducing pain and improving function 3, 5.
• The decision to use imaging guidance should be based on individual patient needs and circumstances, and should take into account the potential benefits and risks of the procedure 3, 4, 6.