What is the workup and management for shoulder and knee pain, including steroid injections and counseling?

Workup and Management of Shoulder and Knee Pain with Steroid Injections

For patients with shoulder and knee pain, corticosteroid injections provide effective short-term pain relief, particularly for acute flares with effusion, but should be considered after initial conservative measures and as part of a comprehensive treatment plan that includes physical therapy and appropriate analgesics. 1

Diagnostic Workup

Shoulder Pain Assessment

1. Clinical Evaluation:

   • Assess for specific conditions: rotator cuff disease, adhesive capsulitis, or full thickness tears
   • Evaluate for spasticity in post-stroke patients 1
   • Check for regional sensory changes, subluxation, and range of motion limitations

2. Imaging:

   • Ultrasound is useful for diagnosing soft tissue injuries 1
   • X-rays to evaluate for structural abnormalities or arthritis

Knee Pain Assessment

1. Clinical Evaluation:

   • Check for effusion, range of motion, and joint stability
   • Assess for radiographic evidence of osteoarthritis
   • Evaluate functional limitations using standardized tools (e.g., WOMAC, Lequesne index)

2. Imaging:

   • X-rays to evaluate joint space narrowing and structural changes
   • Consider ultrasound for soft tissue evaluation

Management Algorithm

First-Line Treatments

1. Non-pharmacological approaches:

   • Patient and family education on positioning and range of motion exercises 1
   • Physical therapy
   • Supportive devices for shoulder subluxation if present 1

2. Oral Analgesics:

   • Start with acetaminophen/paracetamol
   • Consider NSAIDs if inadequate response, particularly with signs of inflammation 1

Second-Line Treatments

For Shoulder Pain:

1. Corticosteroid Injections:

   • Indicated for acute exacerbation of pain 1, 2
   • Provides short-term benefit (1-4 weeks) 2, 3
   • Can be administered into glenohumeral joint or subacromial space 1
   • Superior to oral NSAIDs for functional improvement at 4-6 weeks 4
   • Consider for patients who have failed conservative therapy

2. Alternative Injections:

   • Botulinum toxin for shoulder spasticity (particularly in post-stroke patients) 1, 5
   • Suprascapular nerve blocks may be effective for both nociceptive and neuropathic pain 1

For Knee Pain:

1. Corticosteroid Injections:

   • Indicated for flares of knee pain, especially with effusion 1
   • Provides effective but relatively short-lived benefit (1-4 weeks) 1
   • Evidence level 1B for efficacy 1
   • Long-term use (every 3 months) has been shown to be safe without accelerating joint space narrowing 6

2. Hyaluronic Acid Injections:

   • Consider for knee osteoarthritis when steroid injections provide insufficient relief
   • Provides longer duration of pain relief (several months) but slower onset of action 1
   • Requires 3-5 weekly injections 1

Third-Line Treatments

1. Surgical Options:
   • Joint replacement for knee OA with refractory pain and radiographic evidence of disease 1
   • Consider surgical tenotomy for severe hemiplegic shoulder pain with restricted range of motion 1

Injection Techniques

Shoulder Injections

• Use anatomical landmarks or ultrasound guidance for accuracy
• For glenohumeral joint or subacromial space based on clinical presentation
• Community-based physiotherapy and local steroid injections show similar effectiveness at 6 months 3

Knee Injections

• Use aseptic technique with anatomical landmarks
• Consider ultrasound guidance for increased accuracy
• Ensure proper positioning (seated with knee flexed at 90°)

Follow-up and Monitoring

• Assess response to treatment at 2-4 weeks
• Monitor for adverse effects (skin atrophy, infection, post-injection flare)
• Limit frequency of injections (generally no more than 3-4 per year in the same joint)
• Consider alternative or additional treatments if inadequate response

Important Caveats

• Corticosteroid injections provide short-term relief but do not modify disease progression
• Repeated injections should be approached with caution, though long-term studies show safety 6
• Combination with physical therapy improves outcomes
• Injection efficacy may vary based on underlying pathology and patient characteristics
• For spastic muscles (particularly post-stroke), botulinum toxin injections are more appropriate than corticosteroids 1, 5