What are the indications for steroid shoulder injections in adults over 40 with a history of repetitive shoulder movements or trauma and diagnosed with conditions such as rotator cuff tendinitis, adhesive capsulitis, or bursitis?

Indications for Steroid Shoulder Injections

Steroid shoulder injections are indicated for rotator cuff tendinitis (subacromial injection) and adhesive capsulitis (intra-articular injection), where they provide meaningful short-term pain relief, particularly when higher doses (≥50 mg prednisone equivalent) are used for rotator cuff disease. 1

Primary Indications by Diagnosis

Rotator Cuff Tendinitis/Disease

• Subacromial corticosteroid injection is the appropriate route for rotator cuff tendinitis, demonstrating a relative risk of 3.08 for symptom improvement compared to placebo 1
• The number needed to treat is 3.3 patients to achieve one improvement, making this a clinically meaningful intervention 1
• Higher doses (≥50 mg prednisone equivalent) show superior efficacy with a relative risk of 5.9 for improvement 1
• Subacromial injections appear more effective than NSAIDs, with a number needed to treat of 2.5 1
• However, the American Academy of Orthopaedic Surgeons states they cannot recommend for or against subacromial injections for rotator cuff tears specifically, as one level II study found no significant difference between corticosteroid with lidocaine versus lidocaine alone at 6 weeks 2

Adhesive Capsulitis (Frozen Shoulder)

• Intra-articular corticosteroid injection is the appropriate route for adhesive capsulitis 3
• Evidence suggests possible early benefit over placebo, though the effect may be small and not well-maintained 3
• One trial demonstrated short-term benefit over physiotherapy with a relative risk of 1.66 for success at 7 weeks 3
• Intra-articular injections can be used when conservative measures fail 4

Subacromial Bursitis

• Subacromial injection is indicated when pain is thought to be related to injury or inflammation of the subacromial region (rotator cuff or bursa) 2
• This applies particularly in hemiplegic shoulder pain related to bursal inflammation 2

Glenohumeral Osteoarthritis

• The American Academy of Orthopaedic Surgeons cannot recommend for or against intra-articular corticosteroid injection for glenohumeral osteoarthritis due to insufficient evidence 2, 5
• Current literature neither supports nor refutes this use 2

Clinical Decision Algorithm

When to Consider Injection:

• Significant pain that interferes with function or sleep is the primary indication 2
• Pain duration of at least 3 weeks (acute presentations <3 weeks are excluded from evidence base) 3
• Failed conservative management with NSAIDs or activity modification 1
• Need for rapid symptom control to facilitate rehabilitation 2

When to Repeat Injection:

• Only consider repeat injection if the patient achieved ≥50% pain relief lasting at least 2 months from the first injection 5
• Maximum of two injections with 3-week interval between injections has been studied 6

Critical Contraindications and Pitfalls

Absolute Avoidances:

• Do not use overhead pulley exercises after shoulder corticosteroid injection, as they encourage uncontrolled abduction and can worsen shoulder pathology 5
• Avoid peri-tendon injections due to rupture risk 5
• Do not perform systemic glucocorticoid therapy for shoulder conditions—local injection is preferred 5

Technical Considerations:

• Accurate diagnosis and proper injection technique are critical for satisfactory outcomes 7
• Absolute sterile technique is mandatory, as infections of the subacromial space, though uncommon, lead to debilitating conditions 7
• Accuracy of needle placement varies significantly between techniques and affects efficacy 7

Duration of Benefit

• Subacromial injections for rotator cuff tendinitis are effective for improvement up to a 9-month period 1
• Short-term benefit (up to 6 weeks) is most consistently demonstrated 2
• Long-term maintenance of effect is variable and not well-established 3

Comparative Effectiveness

• Steroid injections are probably more effective than NSAIDs for rotator cuff tendinitis 1
• One study found no difference between subacromial triamcinolone 40 mg versus oral indomethacin 100 mg/day at 6 weeks, though this conflicts with meta-analysis data 6
• For adhesive capsulitis, steroid injection may provide faster initial relief than physiotherapy alone 3