What is the recommended dose of Kenalog (triamcinolone acetonide) for a shoulder injection in a patient with shoulder pain or inflammation?

Recommended Kenalog Dose for Shoulder Injection

For shoulder injections, use 40 mg of triamcinolone acetonide (Kenalog) administered intra-articularly into the glenohumeral joint or into the subacromial space, depending on the underlying pathology. 1, 2

Standard Dosing Protocol

• The FDA-approved dosing range for intra-articular shoulder injection is 5-15 mg for larger joints, though doses up to 40 mg for larger areas have usually been sufficient 2
• Clinical practice guidelines specifically recommend 40 mg triamcinolone acetonide for shoulder pain and inflammatory conditions 1, 3
• The injection should be administered as a single dose, which is often sufficient, though several injections may be needed for adequate symptom relief 2

Evidence Supporting 40 mg Dose

• A randomized controlled trial directly comparing doses demonstrated that 40 mg triamcinolone acetonide provides significantly greater symptom relief than 10 mg for capsulitis of the shoulder 4
• Multiple studies have consistently used 40 mg as the standard dose for subacromial and glenohumeral injections, showing significant pain reduction effects 5, 6, 7
• The 40 mg dose shows optimal pain relief within the first week after injection, with the greatest benefit achieved after the first injection 7

Administration Technique

• Inject deeply using strict aseptic technique into either the glenohumeral joint or subacromial space based on clinical diagnosis 2
• If excessive synovial fluid is present, aspirate some (but not all) before injection to aid pain relief and prevent undue dilution of the steroid 2
• Avoid injecting into surrounding tissues, particularly in the deltoid region, as this may lead to tissue atrophy 2
• The suspension must be shaken before use and injected without delay after withdrawal to prevent settling in the syringe 2

Repeat Injection Considerations

• If a second injection is needed, 40 mg can be repeated, but evidence suggests diminishing returns after more than two injections 7
• The first injection provides the best pain reduction; a second injection may show further improvement, but a third injection shows only slight additional benefit 7
• Allow appropriate time intervals between injections, typically several weeks, as guided by patient response 2

Important Clinical Pitfalls

• Do not inject at sites of active infection 1
• Avoid use in patients with previous hypersensitivity to triamcinolone 1
• Exercise caution in patients with uncontrolled diabetes, heart failure, or severe hypertension 1
• Be aware that the long-term effectiveness of corticosteroid injections for shoulder pain is not well established; they primarily provide short-term relief 8, 3
• Monitor for local adverse effects including skin atrophy, pigmentary changes, and telangiectasias with repeated injections 1
• Repeated injections can suppress the hypothalamic-pituitary-adrenal axis 1

Alternative Dosing in Special Circumstances

• For early adhesive capsulitis, some evidence suggests 20 mg combined with hyaluronidase may be equivalent to 40 mg alone, though 40 mg remains the standard recommendation 9
• In pediatric patients, dosing ranges from 0.11 to 1.6 mg/kg/day, though this is rarely applicable for shoulder injections 2