How to administer a shoulder steroid injection to a patient?

How to Administer a Shoulder Steroid Injection

For shoulder pain, inject 40 mg triamcinolone acetonide intra-articularly into the glenohumeral joint or subacromial space using strict aseptic technique, with ultrasound guidance strongly recommended to ensure accurate placement. 1, 2

Pre-Injection Assessment

• Identify the specific pain source: Determine whether pain originates from the glenohumeral joint (arthritis, capsulitis) or subacromial space (rotator cuff pathology, bursitis) through physical examination and imaging 3, 4
• Use ultrasound or MRI to visualize pathology and guide injection site selection 3
• Verify no contraindications exist, including active infection, tendon rupture risk, or systemic corticosteroid complications 4

Injection Technique

Equipment and Preparation

• Use triamcinolone acetonide 40 mg as the standard dose for shoulder injections 1, 5, 6
• Shake the vial thoroughly before withdrawal to ensure uniform suspension; inspect for clumping or granular appearance (agglomeration) and discard if present 1
• Inject without delay after drawing up medication to prevent settling in the syringe 1
• Employ strict aseptic technique to avoid introducing infection 1

Anatomical Approach

For glenohumeral joint injection:

• Use the posterior approach as the standard technique 6
• Insert needle into the glenohumeral joint space under ultrasound guidance when possible 7, 2
• Accuracy matters significantly: Only 42% of attempted glenohumeral injections without imaging guidance are accurately placed, and accurate placement significantly affects clinical outcomes 2

For subacromial injection:

• Target the subacromial space when pain relates to rotator cuff or bursal inflammation 4
• Use ultrasound guidance to ensure proper needle placement 2

Critical Safety Points

• Never inject directly into tendon substance - only peritendinous injection is acceptable, as intra-tendinous injection inhibits healing, reduces tensile strength, and predisposes to spontaneous rupture 4
• Avoid subcutaneous fat atrophy by ensuring deep, accurate placement 1
• Do not enter blood vessels - aspirate before injecting 1

Dosing Specifics

• Standard dose: 40 mg triamcinolone acetonide for most shoulder conditions 1, 5, 6
• For smaller joints: 5-15 mg; for larger joints like the shoulder: 5-40 mg 1
• 40 mg is superior to 10 mg for symptom relief in frozen shoulder 5
• Maximum of 3 injections spaced 3 weeks apart if initial injection provides insufficient relief 6
• Single injections into multiple joints up to a total of 80 mg have been given safely 1

Post-Injection Management

• Warn patients about post-injection pain flare, which is a recognized complication 3, 4
• Continue physical therapy - the injection facilitates rehabilitation but does not replace it 3, 4
• Monitor for short-term pain relief within 1-3 weeks; long-term pain reduction beyond this period is not well-verified 8, 3
• Expect greater improvement in pain and sleep disturbance than in range of motion 5

Expected Outcomes

• Short-term pain reduction is significant in observational studies for both glenohumeral and subacromial injections 8, 3
• Effectiveness rates of 81-83% have been reported for primary frozen shoulder 6
• Diabetic frozen shoulder responds better to triamcinolone (69% improvement) compared to methylprednisolone (39% improvement) 6
• The effect is primarily on pain relief rather than functional improvement 5, 9

Important Caveats

• Ultrasound guidance dramatically improves accuracy: Without imaging, only 29-42% of injections are accurately placed, and accuracy significantly affects outcomes 2
• Evidence quality is limited: The American Academy of Orthopaedic Surgeons cannot recommend for or against injectable corticosteroids for glenohumeral osteoarthritis due to insufficient high-quality evidence 3, 4
• Long-term efficacy is unproven - benefits are primarily short-term (weeks, not months) 8, 3