What are the indications for a shoulder injection?

Indications for Shoulder Injection

Shoulder injections are primarily indicated for significant pain from various shoulder conditions that have failed conservative management including NSAIDs, physical therapy, and activity modification for 4-6 weeks. 1, 2

Primary Indications

• Rotator Cuff Disease:

  • Symptomatic rotator cuff tears 3
  • Rotator cuff tendinosis 2
  • Impingement syndrome 2

• Joint-Related Conditions:

  • Adhesive capsulitis (frozen shoulder) 4, 2
  • Osteoarthritis of glenohumeral or acromioclavicular joint 4, 2
  • Rheumatoid arthritis 4, 2
  • Acute and subacute bursitis 4
  • Synovitis 4

• Other Specific Conditions:

  • Subdeltoid bursitis 2
  • Acute nonspecific tenosynovitis 4
  • Epicondylitis 4
  • Acute gouty arthritis 4
  • Inflammatory conditions of the long head of biceps 2

Treatment Algorithm

1. First-Line Treatment (4-6 weeks):

   • NSAIDs (oral or topical)
   • Activity modification
   • Physical therapy
   • Acetaminophen if NSAIDs contraindicated 1

2. Consider Injection When:

   • Pain persists despite 4-6 weeks of conservative management 1
   • Pain significantly impacts function and quality of life 1
   • Acute exacerbation requiring rapid symptom relief 4

3. Injection Specifics:

   • Limit to 2-3 injections with 4-6 weeks between injections 1
   • Corticosteroid (e.g., triamcinolone acetonide) with local anesthetic 4, 5
   • Target specific anatomical location based on condition:
     • Glenohumeral joint for adhesive capsulitis, osteoarthritis
     • Subacromial space for impingement, rotator cuff tendinosis
     • Acromioclavicular joint for AC joint arthritis
     • Bicipital groove for biceps tendinitis 2

Evidence Quality and Considerations

The evidence supporting shoulder injections shows variable efficacy:

• For rotator cuff disease, studies show small short-term benefits over placebo, but no significant benefit over NSAIDs 6
• For adhesive capsulitis, intra-articular steroid injections may provide early benefit over placebo and short-term benefit over physiotherapy alone 6
• Injection accuracy significantly impacts outcomes - anterior approach (94% accuracy) may be superior to posterior approach (78% accuracy) when performed without ultrasound guidance 5

Important Caveats

• Avoid injecting directly into tendons 7
• Repeated injections (beyond 2-3) are not recommended due to potential tissue damage 7, 1
• Consider ultrasound guidance for improved accuracy, especially for glenohumeral injections 5
• Effectiveness may be limited to short-term relief; benefits often not well-maintained long-term 6
• For chronic cases unresponsive to standard injections, consider specialized approaches such as osteopathic manipulation 8
• If no improvement after 3-6 months of conservative management including injections, consider surgical consultation 1

Special Populations

• Diabetic patients may experience temporary elevation in blood glucose and may respond less favorably to conservative measures 1
• Patients with full-thickness rotator cuff tears may require different management approaches 5