From the Guidelines
I strongly recommend proceeding with a fluoroscopy-guided corticosteroid injection for this patient with persistent shoulder pain, despite Kenalog not being registered in PCMU, as alternative corticosteroids can be used effectively. The patient's clinical presentation and imaging findings, including a tender biceps groove with positive Hawkins and Jobs tests, partial thickness tears of the supraspinatus and infraspinatus, mild tendinosis, and subacromial bursitis, support the use of a corticosteroid injection to reduce inflammation and pain 1. Given the patient's persistent symptoms despite conservative management with shockwave therapy and extensive physical therapy, a corticosteroid injection is a reasonable next step. The injection should be combined with a local anesthetic like lidocaine 1% (3-5ml) for immediate pain relief. Following the injection, the patient should rest the shoulder for 48-72 hours and then resume a structured physical therapy program focusing on rotator cuff strengthening and scapular stabilization exercises, as eccentric strengthening has been shown to be an effective treatment for tendinopathy and may reverse degenerative changes 1. It is essential to inform the patient that while corticosteroid injections typically provide good short to medium-term relief, they may not address the underlying structural issues, and a comprehensive rehabilitation program remains essential for long-term improvement. If symptoms persist after injection and continued rehabilitation, surgical options such as arthroscopic debridement or repair may need to be considered, as surgery is an effective option in carefully selected patients who have failed three to six months of conservative therapy 1. Additionally, factors such as increasing age, MRI tear characteristics, and workers' compensation status may correlate with less favorable outcomes after rotator cuff surgery, and should be taken into consideration when advising the patient 1.
From the FDA Drug Label
Intramuscular Where oral therapy is not feasible, injectable corticosteroid therapy, including KENALOG-40 Injection and KENALOG-80 Injection (triamcinolone acetonide injectable suspension, USP) is indicated for intramuscular use as follows: Intra-Articular The intra-articular or soft tissue administration of KENALOG-40 Injection and KENALOG-80 Injection are indicated as adjunctive therapy for short-term administration (to tide the patient over an acute episode or exacerbation) in acute gouty arthritis, acute and subacute bursitis, acute nonspecific tenosynovitis, epicondylitis, rheumatoid arthritis, synovitis of osteoarthritis.
The patient has sub deltoid bursitis, which is an indication for intra-articular administration of Kenalog. Given the patient's symptoms and diagnosis, Fluoroscopy Guided joint injection for Kenalog may be considered as an adjunctive therapy for short-term administration to tide the patient over an acute episode or exacerbation of sub deltoid bursitis 2.
- Key points:
- Patient has sub deltoid bursitis
- Kenalog is indicated for intra-articular administration in cases of subacute bursitis
- Fluoroscopy Guided joint injection for Kenalog may be considered as an adjunctive therapy for short-term administration.
From the Research
Evaluation of Shoulder Pain Management
- The patient has been experiencing shoulder pain for 8 months, with a tender biceps groove and positive Hawkins and Jobs tests.
- An MRI conducted in February 2025 revealed a partial thickness tear of the supraspinatus and infraspinatus at the site of attachment, mild tendinosis, and subdeltoid bursitis.
- The patient has undergone 5 sessions of shockwave therapy and 15 sessions of physiotherapy, with the last session on April 10,2025.
Requested Service: Fluoroscopy-Guided Joint Injection for Kenalog
- The patient is requesting a fluoroscopy-guided joint injection for Kenalog, a medication not registered in PCMU.
- According to a study published in 2023 3, fluoroscopy guidance is commonly utilized for injections in the upper extremity, with increased accuracy for injection placement compared to blind injection.
- Another study published in 2014 4 compared the short-term effects and safety of ultrasound-guided and fluoroscopy-guided sacroiliac joint intra-articular injections, finding that fluoroscopy-guided injections exhibited greater accuracy.
Alternative Treatment Options
- A study published in 2023 5 compared the efficacy of intra-articular platelet-rich plasma and corticosteroid injections in the management of frozen shoulder, finding that platelet-rich plasma injections demonstrated better long-term outcomes.
- Another study published in 2019 6 provided a comprehensive review of fluoroscopic-guided foot and ankle injections, emphasizing the importance of pre-procedural planning and relevant anatomy.
- A pilot study published in 2017 7 assessed the feasibility and safety of concomitant intra-articular knee injection of mesenchymal stem cells and platelet-rich plasma under fluoroscopic guidance to treat patellofemoral osteoarthritis, finding significant improvement in clinical outcomes.
Considerations for Kenalog Injection
- The use of Kenalog, a corticosteroid, may be considered for the treatment of shoulder pain and inflammation, but its efficacy and safety should be evaluated in the context of the patient's specific condition and medical history.
- The fact that Kenalog is not registered in PCMU may be a consideration in the decision-making process, and alternative treatment options should be explored.