Is it advisable to administer bilateral steroid injections to a patient with recurrent shoulder pain who previously responded well to a single steroid injection?

Bilateral Steroid Injections for Recurrent Shoulder Pain: Recommendations

Bilateral steroid injections for recurrent shoulder pain should be used cautiously and only as a bridging therapy while initiating more definitive treatment such as physical therapy, not as a standalone or repeated treatment strategy.

Assessment of Current Situation

The patient is a 49-year-old male with:

• Recurrent bilateral shoulder pain
• Previous steroid injection in January 2025 with temporary relief
• Now requesting bilateral injections for July 2025

Evidence-Based Recommendations

Steroid Injections: Role and Limitations

1. Short-term bridging therapy only

   • Intra-articular glucocorticoid injections are recommended as bridging options, awaiting the effect of other agents, not as definitive treatment 1
   • Steroid injections provide moderate short-term benefit for reducing pain and improving function, typically lasting several weeks 2

2. Concerns with multiple injections

   • Multiple steroid injections may compromise the integrity of the rotator cuff, potentially affecting subsequent repair attempts 1
   • Long-term use of glucocorticoids should be avoided 1
   • Steroid injections can have toxic effects on articular cartilage with repeated use 2

Proper Management Approach

1. First-line treatment

   • Physical therapy should be the cornerstone of treatment 1
   • NSAIDs/COXIBs should be considered as first-line pharmacological therapy 1

2. Injection technique if proceeding

   • Ensure proper aseptic technique and anatomical placement 3
   • Use appropriate dose based on joint size (20-80mg for large joints like shoulders) 3
   • Consider ultrasound guidance for accurate placement 1
   • Obtain informed consent and document the procedure 1

3. Important precautions

   • Monitor for systemic absorption, especially with bilateral injections 4
   • Be aware that even local injections can have systemic effects lasting for weeks 4
   • Potential side effects include hyperglycemia, immune suppression, and infection risk 4

Decision Algorithm

1. Before proceeding with bilateral injections:

   • Confirm diagnosis with proper clinical examination
   • Rule out contraindications (local infection, coagulopathy)
   • Discuss risks/benefits with patient, emphasizing temporary nature of relief
   • Establish a comprehensive treatment plan including physical therapy

2. If proceeding with injection:

   • Use minimal effective dose
   • Schedule physical therapy to begin immediately after injection
   • Plan for no more than 3-4 injections per year per joint
   • Document informed consent regarding potential risks

3. Alternative approaches to consider:

   • Sequential rather than simultaneous bilateral injections
   • Trial of oral NSAIDs before repeat injection
   • Comprehensive rehabilitation program

Important Cautions and Pitfalls

• Avoid repeated injections: Multiple steroid injections may lead to tendon weakening and accelerated joint degeneration 1, 2
• Systemic effects: Even local injections can cause systemic effects including hyperglycemia, immune suppression, and HPA axis suppression 4
• Masking symptoms: Pain relief without addressing underlying cause may lead to continued joint damage
• Diminishing returns: Effectiveness typically decreases with repeated injections

Conclusion for This Case

While bilateral steroid injections can be performed for this patient with recurrent shoulder pain, they should be viewed as a temporary measure while initiating physical therapy. The patient should be informed that this is not a long-term solution, and a comprehensive rehabilitation program should be implemented immediately. Spacing injections at least 3-4 months apart is advisable to minimize potential adverse effects on tendon integrity.