Can a steroid injection be administered in a shoulder with underlying osteopenia (bone loss)?

From the Guidelines

Steroid injections can be administered in a shoulder with underlying osteopenia, but caution is advised to minimize the risk of further bone density reduction. Corticosteroid injections, such as methylprednisolone (40-80 mg) or triamcinolone (20-40 mg), often mixed with a local anesthetic like lidocaine, can help reduce inflammation and pain in the shoulder joint 1. However, repeated steroid injections (typically more than 3-4 per year) may potentially worsen osteopenia by further decreasing bone mineral density. This occurs because corticosteroids can inhibit osteoblast activity (cells that build bone) and increase osteoclast activity (cells that break down bone) 1.

Key Considerations

• The frequency of injections should be limited to no more than 2-3 per year for patients with osteopenia.
• Alternative treatments, such as physical therapy, oral anti-inflammatory medications, or other joint preservation strategies, should be considered.
• A comprehensive treatment plan that includes measures to maintain or improve bone health, such as supplementation of Vitamin D and adequate calcium intake, is recommended 1.
• The decision to administer steroid injections should be made after weighing the benefits of pain relief against the potential risks of bone density reduction.

Treatment Approach

• Corticosteroid injections should be used judiciously in patients with osteopenia, taking into account the potential risks and benefits.
• Patients should be monitored regularly for changes in bone density and adjusted their treatment plan accordingly.
• A multidisciplinary approach, including orthopedic, rheumatologic, and primary care providers, may be necessary to optimize care for patients with osteopenia and shoulder pain.

From the FDA Drug Label

Corticosteroids decrease bone formation and increase bone resorption both through their effect on calcium regulation (i.e., decreasing absorption and increasing excretion) and inhibition of osteoblast function. This, together with a decrease in the protein matrix of the bone secondary to an increase in protein catabolism, and reduced sex hormone production, may lead to inhibition of bone growth in pediatric patients and the development of osteoporosis at any age. Special consideration should be given to patients at increased risk of osteoporosis (i. e., postmenopausal women) before initiating corticosteroid therapy. Intra-articularly injected corticosteroids may be systemically absorbed. Corticosteroid injection into unstable joints is generally not recommended.

Administration of steroid injection in a shoulder with underlying osteopenia is not recommended due to the potential for further bone loss and osteoporosis. The decision to administer a steroid injection should be made with caution, considering the potential risks and benefits, especially in patients with underlying osteopenia. 2

From the Research

Administration of Steroid Injections in Shoulders with Underlying Osteopenia

• The administration of steroid injections in shoulders with underlying osteopenia is a complex issue, and the available evidence provides some insights into the potential effects of steroid injections on bone density and fracture risk 3.
• A systematic review and critical appraisal of current literature found that epidural steroid injections were associated with significantly decreased bone mineral density (BMD) in four out of six included studies, and with increased risk of vertebral fracture in one out of two included studies 3.
• However, the study also found that the risk of osteopenia and osteoporosis was lower in patients who were receiving anti-osteoporotic medication during the treatment course, suggesting that concurrent treatment with anti-osteoporotic medication may mitigate the negative effects of steroid injections on bone density 3.
• Another study found that bisphosphonates, a type of anti-osteoporotic medication, have the strongest evidence of preventing steroid-induced bone loss, and that patients with osteoporosis or osteopenia with a T-score below -1.5 should receive antiresorptive treatment during steroid therapy 4.
• In terms of the specific context of shoulder injections, a study found that subacromial triamcinolone acetonide injections were effective in reducing pain in patients with shoulder impingement, but did not investigate the effects on bone density 5.

Considerations for Administration of Steroid Injections

• The available evidence suggests that steroid injections should be used with caution in patients with underlying osteopenia, particularly in those at high risk of osteoporotic fractures, such as postmenopausal women 3.
• Patients receiving steroid injections should be assessed for their individual risk of bone loss, and anti-osteoporotic medication should be considered as part of the treatment regimen 4, 3.
• The type and dose of steroid injection, as well as the frequency of administration, should be carefully considered to minimize the risk of adverse effects on bone density 3.