What are the treatment options for a gel shoulder injection?

Treatment Options for Gel Shoulder Injections

For shoulder pain, corticosteroid injections are a widely used treatment option when conservative measures have failed, though their effectiveness varies depending on the underlying condition.

Injection Approaches and Techniques

• Corticosteroid injections can be administered into different areas of the shoulder depending on the pathology:

  • Glenohumeral joint injections for osteoarthritis, adhesive capsulitis, and rheumatoid arthritis 1
  • Subacromial injections for conditions including adhesive capsulitis, subdeltoid bursitis, impingement syndrome, and rotator cuff tendinosis 1
  • Acromioclavicular joint injections for osteoarthritis and distal clavicular osteolysis 1

• Injection technique considerations:

  • Aseptic technique is mandatory to prevent infection 2, 3
  • Patient should be in a sitting position for comfort and effectiveness 3
  • Avoid injecting directly into tendons; instead target the overlying bursal space or tendon sheath 3
  • For intra-articular injections, the anterior approach (94% accuracy) is superior to the posterior approach (78% accuracy) when performed without ultrasound guidance 4

Medication Options and Dosing

• Corticosteroid options:

  • Triamcinolone acetonide: 5-15 mg for larger joints, with doses up to 40 mg being used for larger areas 2
  • If excessive synovial fluid is present, some should be aspirated before injection to prevent dilution of the steroid 2

• Alternative injectable options:

  • Sodium hyaluronate (viscosupplementation) may be considered for glenohumeral osteoarthritis 5, 6
  • Ozone injections and pulsed radiofrequency application have shown effectiveness for adhesive capsulitis 7

Specific Conditions and Recommendations

• For hemiplegic shoulder pain:

  • Botulinum toxin injections can be useful to reduce severe hypertonicity in hemiplegic shoulder muscles (Class IIa, Level A evidence) 8
  • Suprascapular nerve blocks may be considered as an adjunctive treatment (Class IIb, Level B evidence) 8
  • Subacromial or glenohumeral corticosteroid injections for inflammation have uncertain effectiveness (Class IIb, Level B evidence) 8

• For adhesive capsulitis:

  • Corticosteroid injections into the glenohumeral joint or subacromial space can provide significant short-term pain reduction 8
  • Active range of motion should be increased gradually in conjunction with alignment restoration and strengthening of weak shoulder girdle muscles 8

• For subchondral cysts in the greater tuberosity:

  • MRI is preferred for visualization of the cyst and ruling out other pathologies 5
  • Consider corticosteroid injection if pain is associated with the subchondral cyst and conservative measures have failed 5

Important Precautions and Limitations

• Repeated injections are not advised due to potential tissue damage 3
• The corticosteroid solution should not be injected directly into tendons 3
• Proper follow-up and complementary treatments (physical therapy, activity modification) are essential for effective outcomes 1
• For persistent pain unresponsive to injections, surgical options may need to be considered 5
• Overhead pulley exercises are not recommended for hemiplegic shoulder pain (Class III, Level C evidence) 8

Treatment Algorithm

1. First-line treatment: Conservative management with NSAIDs, physical therapy, and activity modification 1
2. If inadequate response after 4-6 weeks: Consider corticosteroid injection based on specific pathology 5, 1
3. For specific conditions:
   • Hemiplegic shoulder with spasticity: Consider botulinum toxin injection 8
   • Adhesive capsulitis: Glenohumeral or subacromial corticosteroid injection 8
   • Osteoarthritis: Consider viscosupplementation if corticosteroid injection fails 5, 6
4. Monitor response and consider alternative approaches if inadequate relief after 2-3 months 5, 1