The patient, who cannot start physical therapy for a while and remains in pain after receiving ketorolac (Toradol) in the office, is asking whether a corticosteroid (cortisone) injection is an appropriate option and if she needs to see an orthopedic surgeon or pain specialist for the injection.

Corticosteroid Injection is an Appropriate Option and Can Be Administered in Your Office

Yes, a corticosteroid injection is a reasonable option for your patient's ongoing pain, and depending on the joint involved and your training, you may be able to perform this in your office without requiring referral to orthopedics or pain management.

Evidence Supporting Corticosteroid Injections

The most recent and highest-quality guidelines strongly support intra-articular corticosteroid injections for symptomatic joint pain:

• For knee osteoarthritis: The 2020 ACR/Arthritis Foundation guideline strongly recommends intra-articular glucocorticoid injections for knee OA 1, 2. These provide effective short-term pain relief, typically within 1-2 weeks 3.

• For hip osteoarthritis: Similarly strongly recommended by the same guideline 1, 2.

• For shoulder conditions: Evidence supports subacromial corticosteroid injections for rotator cuff problems and impingement, though the recommendation is less definitive 4.

The evidence consistently demonstrates that corticosteroid injections provide clinically meaningful pain relief for 1-4 weeks, with some benefit extending to 16-24 weeks 3. While the duration is relatively short-term, this can serve as a bridge until physical therapy becomes available.

Who Should Perform the Injection?

You do not necessarily need to refer to orthopedics or pain management. The decision depends on:

You Can Perform in Office If:

• The joint is a knee or hand - these can be injected without imaging guidance 1, 2
• You have appropriate training and comfort with the procedure
• The patient has clear clinical findings (e.g., effusion, localized tenderness)

Refer for Imaging-Guided Injection If:

• The joint is a hip - ultrasound guidance is strongly recommended for hip injections 1, 2
• You lack confidence in anatomic landmarks
• Previous blind injections have failed
• The diagnosis is uncertain

The 2021 EULAR recommendations emphasize that various healthcare professionals (including primary care physicians, rheumatologists, and orthopedists) routinely perform these procedures, though training levels vary by country 5.

Important Clinical Considerations

Timing Concerns:

Critical caveat: If the patient may eventually require surgery, be aware that performing a corticosteroid injection within 3 months of joint surgery increases infection risk 6. However, if surgery is not imminent, this should not deter appropriate pain management.

Patient Selection:

• Corticosteroid injections work particularly well for acute flares or when effusion is present 7
• Patients with diabetes should be counseled about transient hyperglycemia risk 6, 8
• Use the lowest effective dose and avoid repeated frequent injections 8

Informed Consent:

The patient must be informed about 5:

• Expected benefits (short-term pain relief, typically 1-4 weeks of significant improvement)
• Potential risks (infection, hyperglycemia if diabetic, theoretical cartilage concerns)
• Alternative options
• The temporary nature of relief

Post-Injection Instructions:

• Avoid overuse of the injected joint for 24 hours, but do not immobilize 5
• Pain relief typically begins within 1 week 3

Alternative: Ketorolac Injection

Recent evidence suggests ketorolac (Toradol) injection may be an alternative to corticosteroids, particularly if the patient has contraindications to steroids or concerns about repeated corticosteroid exposure:

• A 2026 study found ketorolac hip injections provided greater pain relief than corticosteroids with similar duration of action 9
• Multiple studies show ketorolac is non-inferior to corticosteroids for shoulder impingement 10, 11 and knee OA 12
• Ketorolac avoids corticosteroid-specific risks (hyperglycemia, potential cartilage toxicity, infection risk if surgery needed soon) 13

However, this is still emerging evidence and not yet incorporated into major guidelines. Corticosteroids remain the standard of care with the strongest evidence base.

Bottom Line Algorithm

1. Identify the joint causing pain
2. If knee or hand: You can inject in office with appropriate training
3. If hip or uncertain anatomy: Refer for ultrasound-guided injection
4. If diabetes: Counsel about glucose monitoring; consider ketorolac alternative
5. If surgery possible within 3 months: Discuss risks vs. benefits carefully
6. Obtain informed consent documenting discussion of risks/benefits
7. Use long-acting corticosteroid (e.g., triamcinolone, methylprednisolone) 7
8. Instruct patient: Avoid overuse for 24 hours, expect relief within 1 week
9. Plan for PT once available, as injection is a bridge therapy, not definitive treatment