What is the recommended treatment for a shoulder injection?

Treatment Recommendations for Shoulder Injection

For shoulder pain management, intra-articular corticosteroid injection is recommended as an effective treatment option, with triamcinolone acetonide 40mg being the preferred medication for most cases. 1

Assessment and Diagnosis

• Perform a thorough musculoskeletal evaluation to identify:

  • Presence of spasticity
  • Joint subluxation
  • Regional sensory changes 2
  • Underlying pathology (adhesive capsulitis, bursitis, rotator cuff tear) 2

• Consider ultrasound as a diagnostic tool for shoulder soft tissue injury 2

• Ultrasound guidance is recommended for shoulder injections to ensure accurate placement 1

Treatment Algorithm

First-line Treatment:

1. Intra-articular corticosteroid injection

   • Medication: Triamcinolone acetonide 40mg for larger joints like the shoulder 3
   • Lower doses (20mg) may be equally effective for periarticular shoulder disorders 4
   • Provides significant short-term pain relief lasting 4-8 weeks 1

2. Injection technique:

   • Use strict aseptic technique (mandatory) 1, 3
   • Change needles between drawing medication and injecting 1
   • Consider local anesthetic for patient comfort 1
   • Aspirate synovial fluid if present to confirm intra-articular placement 1
   • Avoid injecting directly into tendons 5

For hemiplegic shoulder pain:

1. For spasticity-related pain:

   • Botulinum toxin injection into hypertronic shoulder muscles (Class IIa, Level A evidence) 2
   • Target muscles: pectoralis major, infraspinatus, subscapularis 2

2. For inflammation-related pain:

   • Subacromial or glenohumeral corticosteroid injection 2
   • Note: Evidence for this approach is not well established (Class IIb, Level B) 2

3. For neuropathic pain components:

   • Suprascapular nerve block (Class IIb, Level B evidence) 2
   • Neuromodulating pain medications for patients with sensory changes, allodynia, or hyperpathia 2

Additional Interventions

• Physical measures:

  • Patient education on proper positioning and range of motion exercises 2
  • Supportive devices and slings for shoulder subluxation 2
  • Avoid overhead pulley exercises (Class III, Level C evidence - not recommended) 2

• For severe cases with limited response:

  • Neuromuscular electrical stimulation (NMES) may be considered 2
  • Surgical tenotomy of pectoralis major, lattisimus dorsi, teres major, or subscapularis may be considered for severe hemiplegia with restricted range of motion 2

Important Considerations and Precautions

• Repeated corticosteroid injections may have potential long-term negative effects on bone health and joint structure 1
• Avoid corticosteroid injections for 3 months preceding joint replacement surgery 1
• Monitor patients with diabetes for transient hyperglycemia during days 1-3 post-injection 1
• Limit repeated injections to minimize risk of tissue atrophy 5
• The risk of infection with proper technique is very low but should be discussed with patients 1

Evidence on Dosing

Research shows that 40mg of triamcinolone acetonide provides greater symptom relief than 10mg for frozen shoulder 6, but there may be no significant difference between 40mg and 20mg doses for periarticular shoulder disorders 4. For diabetic patients with frozen shoulder, triamcinolone acetonide appears more effective than methylprednisolone acetate 7.

Low-dose steroid (20mg triamcinolone) combined with hyaluronidase may be as effective as high-dose steroid (40mg) in early adhesive capsulitis 8.