Is a hydrocortisone (corticosteroid) injection effective for treating shoulder pain?

Hydrocortisone Injection for Shoulder Pain

Corticosteroid injections, including hydrocortisone, are effective for short-term pain relief in shoulder conditions, particularly when administered into the subacromial space for rotator cuff tendinopathy, with a number needed to treat of 3.3 patients to achieve one improvement. 1

Evidence-Based Effectiveness

Subacromial Injection for Rotator Cuff Tendinopathy

• Subacromial corticosteroid injections demonstrate strong efficacy with a relative risk for improvement of 3.08 (95% CI = 1.94 to 4.87) compared to placebo, providing benefit for up to 9 months 1
• Higher doses (≥50 mg prednisone equivalent) show superior results with a relative risk of 5.9 (95% CI = 2.8 to 12.6) 1
• Corticosteroid injections outperform NSAIDs alone, with a number needed to treat of 2.5 patients for one additional improvement 1

Intra-articular (Glenohumeral) Injection

• For glenohumeral joint conditions, the evidence is less robust - the American Academy of Orthopaedic Surgeons cannot recommend for or against injectable corticosteroids for glenohumeral osteoarthritis (Grade I recommendation, Level V evidence) 2
• Observational data shows significant short-term pain reduction after glenohumeral injection, but long-term pain reduction has not been verified 2

Hemiplegic Shoulder Pain (Post-Stroke)

• Intra-articular triamcinolone injections have significant effects on pain in post-stroke shoulder pain 3
• Subacromial corticosteroid injections are specifically recommended when pain is related to injury or inflammation of the subacromial region (rotator cuff or bursa) in hemiplegic shoulders (Evidence Level B) 3

Clinical Algorithm for Use

When to Consider Injection

1. After conservative measures have been attempted including NSAIDs, physical therapy, and activity modification 4, 5
2. Specific indications include:
   • Rotator cuff tendinopathy with subacromial impingement 4, 1
   • Adhesive capsulitis (both glenohumeral and subacromial approaches) 4
   • Subdeltoid bursitis 4
   • Subacromial inflammation or rotator cuff injury 3

Injection Site Selection

• Choose subacromial injection for rotator cuff tendinopathy - this has the strongest evidence for effectiveness 1
• Use glenohumeral (intra-articular) injection for adhesive capsulitis, osteoarthritis, or rheumatoid arthritis, recognizing weaker evidence 4, 2
• Acromioclavicular joint injection for AC joint osteoarthritis or distal clavicular osteolysis 4

Important Caveats and Pitfalls

Short-Term vs Long-Term Outcomes

• Corticosteroid injections provide excellent short-term benefit (up to 12 weeks) but may be less effective or even worse than other treatments in the intermediate and long term 6
• For lateral epicondylalgia specifically, corticosteroid injections were more effective than no intervention short-term but less effective long-term 6

Safety Concerns

• Never inject directly into the tendon substance - peritendinous injection only, as intra-tendinous injection may inhibit healing, reduce tensile strength, and predispose to spontaneous rupture 3
• Adverse effects occur in 82% of corticosteroid injection trials, with increased risk of tissue atrophy for Achilles and patellar tendons (though not elbow tendons) compared to placebo 6
• Post-injection pain flare is a recognized complication 2

Dosing Considerations

• Higher doses (≥50 mg prednisone equivalent) appear more effective than lower doses for subacromial injection 1
• Hydrocortisone is less potent than triamcinolone or methylprednisolone - consider using 40 mg methylprednisolone acetate with 1% lidocaine (total volume 1 ml) for subacromial injection 7

Follow-Up Strategy

• Monitor for short-term pain relief and continue appropriate physical therapy - the injection should facilitate rehabilitation, not replace it 2
• Expect maximal benefit within 2-4 weeks 7
• If pain persists beyond 12 weeks or recurs, consider alternative diagnoses or treatments rather than repeated injections 6