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Frequently asked questions about shoulder pain and injections

What shoulder conditions can be effectively managed with an ultrasound-guided injection?

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Sub-acromial shoulder bursitis

The sub-acromial bursa is a thin fluid-containing sac located within the shoulder joint (between the ball and socket joint, underneath the acromion and on top of the rotator cuff tendons). It ensures smooth movement as we lift our arms. Sub-acromial bursitis refers to inflammation of this bursa and usually results in shoulder pain, particularly when lifting your arm above the head level. It is one of the most common conditions we see in our practice. To find out more, please read our article about Sub-acromial shoulder bursitis. Ultrasound-guided cortisone injection therapy is a recognised treatment option.

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subacromial bursitis ultrasound guided steroid injection

Rotator cuff pain/tear

Rotator cuff pain is a spectrum of conditions that includes tendon inflammation (tendinosis), partial thickness and full-thickness tears to the rotator cuff tendons. Rotator cuff pain can be a sequela of shoulder impingement and is often associated with subacromial bursa inflammation (sub-acromial bursitis). Another cause of rotator cuff pain is calcific tendonitis. Please read our article about Rotator cuff pain/tear to learn more details.

subacromial bursitis ultrasound guided steroid injection

Sub-acromial shoulder impingement

Shoulder impingement is an umbrella term to describe a specific type of shoulder pain resulting from some conditions (Rotator cuff pain, Subacromial bursitis, and Acromioclavicular joint arthritis). Other conditions included are Long head of biceps tendon pain and sometimes Shoulder calcific tendonitis.

 

To find out more, please see our article about Sub-acromial shoulder impingement

Shoulder calcific tendonitis

Calcific tendonitis (calcific tendinopathy) is the deposition of calcium material within the rotator cuff tendons. The patients usually have significant shoulder pain and do not recall a specific reason. The shoulder movements can be significantly restricted. The condition can be mistaken for a rotator cuff tear or frozen shoulder. A shoulder ultrasound is excellent for the assessment and to guide any treatment, like a barbotage procedure. The shoulder x-ray below shows a focal area of calcification (arrow). To find out more, please see our article about Shoulder calcific tendonitis.

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Ultrasound guided barbotage for calcific tendonitis

Frozen shoulder

Frozen shoulder (adhesive capsulitis) refers to inflammation and stiffness of the shoulder joint secondary to capsular inflammation. The capsule is a thin tissue layer surrounding the ball and socket shoulder joint. In Frozen shoulder, the joint capsule will become inflamed and stiff, resulting in shoulder pain and restriction of shoulder movement. To find out more, please read our article about Frozen shoulder. Ultrasound can guide the treatment, including ultrasound-guided shoulder joint cortisone injection and hydrodilation.

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Shoulder (glenohumeral) joint arthritis

Osteoarthritis (OA) of the shoulder refers to the wear and tear changes that can affect the joint cartilage, similar to other joints in our body. The shoulder joint (the glenohumeral joint) is a ball and socket type joint. The ball is formed by the humeral head (the upper end of the arm bone), and the socket is formed by the glenoid, part of the shoulder blade that articulates with the humerus. Both the ball and socket are covered by “cartilage”. This protective layer lines the joints in our body to ensure smooth and frictionless joint movement. In Shoulder osteoarthritis, the cartilage will get thinner and over time, it might get disrupted entirely. This progressive and degenerative process is referred to as “osteoarthritis”. To learn more, please see our article Shoulder (glenohumeral) joint arthritis.

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Ultrasound guided shoulder joint steroid injection

Acromioclavicular joint arthritis

The acromioclavicular joint is the articulation between the clavicle (collar bone) and the acromion (part of the shoulder blade). It is a small joint at the top of the shoulder but undergoes considerable stress during daily activities and when exercising. It is often an underappreciated cause of shoulder pain. The joint can also become painful secondary to injuries or wear and tear changes that increase with age. It is different from the main ball and socket shoulder joint which is formed by the humeral head (the upper end of the arm bone) and the glenoid (part of the shoulder blade). Ultrasound-guided steroid injections can be used in the management of AC joint pain. To find out more, please see our article about Acromioclavicular joint arthritis.

Ultrasound guided acromioclavicular (AC) joint steroid injection

Long head of biceps tendon pain

Biceps tendinitis refers to inflammation of the biceps tendon. The tendon runs at the front of the shoulder/upper arm and inflammation here typically results in pain at the front of the shoulder. It is more common in people who do weight lifting, and also in overhead sports activities like tennis. To learn more, please see our article Long head of biceps tendon pain.

What are the different ultrasound-guided treatments options available for shoulder pain?

The ultrasound-guided treatment options to help in the management of shoulder conditions include:

To find out more, please click on the relevant treatment option.

Should shoulder injections be done under ultrasound guidance?

Yes. This is our routine practice, as plenty of evidence supports ultrasound guidance when performing Steroid Injection in Shoulder. Doing shoulder injections under ultrasound guidance allows for direct visualization of the needle to ensure accurate placement into the area of pain/inflammation (like a bursa, an arthritic joint, or an inflamed tendon sheath). Ultrasound guidance results in more accurate, less painful, and faster procedures, with better outcomes than these injections without guidance. Ultrasound guidance avoids sensitive structures (like nerves and vessels) during the procedure.

What is a shoulder cortisone injection?

Corticosteroid (cortisone) is a potent anti-inflammatory medicine routinely used to manage inflammatory conditions (like bursitis, arthritis and tendinosis). A cortisone injection will reduce the inflammation in the bursa and allow you to manage the condition, usually by undergoing physiotherapy and strengthening the rotator cuff muscles.

Do I need a shoulder cortisone injection?

Generally, the management of most shoulder conditions starts with physiotherapy treatment and progressive rehabilitation. The duration of this depends on the condition. If the response from the above is poor or not satisfactory, then an ultrasound-guided shoulder treatment option may be considered. Indications for injection therapy also include severe persistent shoulder pain refractory to conservative treatment and affecting your sleep, daily routine, and sports activities. Injection therapy can be very useful in reducing pain and improving function, allowing for more effective rehabilitation. We always advise performing Steroid Shoulder Injections under ultrasound guidance by an experienced doctor to ensure accurate medicine delivery to the targeted area.

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Are shoulder cortisone injections safe?

These injections are generally very safe and routinely done in our practise. There is minimal risk of infection (about 1:10.000). The procedure will be explained to you in detail during your appointment, and all your questions will be addressed. To find out more about cortisone injection in general, please see our FAQs.

What are the commonly used steroid medicines in shoulder injections?

Triamcinolone (Kenalog) and methylprednisolone (Depo-medrone) are commonly used steroid injections for musculoskeletal conditions. These preparations are long-acting steroid injections generally take a few days to start working.

How long will the effect of a shoulder cortisone injection last?

Current evidence suggests that cortisone can improve pain and function for up to 3 months, but in some cases, it can last longer. The injections usually also contain a local anaesthetic that provides immediate pain relief lasting a few hours.

Do steroid injections just hide/mask the pain?

Steroid injections do not just mask or hide the pain, but they reduce the inflammation in the targeted area, thus providing a strong and local anti-inflammatory effect to help control the symptoms and allow the patient to manage the condition, usually by undergoing effective rehabilitation.

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How many shoulder injections can I have?

We recommend reducing the number of cortisone shoulder injections by combining any injection therapy with an effective physiotherapy programme to address the underlying cause. Repeated steroid injection into the same area should be avoided if the previous injection was less than 3-4 months ago.

  • Certain shoulder conditions, because of their degenerative nature (like shoulder and acromioclavicular joint arthritis), may require repeated injections.

  • If the response from a first hydro dilatation procedure for the management of a frozen shoulder or barbotage for the management of calcific tendonitis is partial, then a repeat procedure is usually considered.

  • In subacromial bursitis, we may consider repeating injections to prolong the period of pain relief and allow more effective rehabilitation.

Are shoulder injections painful?

Pain is very subjective, and people have different pain thresholds. Generally, shoulder injections are well-tolerated, and most patients experience minimal or no pain during the procedure. The corticosteroid is usually mixed with a local anaesthetic (numbing medicine) to enhance pain relief. We use ultrasound guidance to ensure the procedure is quick and efficient.

How long should I rest after a shoulder injection?

Usually, we advise patients to rest for 48-72 hours after having a shoulder injection. This can vary depending on the type of treatment and severity of the condition. Usually, patients who have a sub-acromial bursa corticosteroid injection are usually advised to rest for 48 hours, while patients with a more advanced procedure like hydro dilatation or barbotage for calcific tendonitis may be advised to rest for 5-7 days.

Sub-specialist Consultant Musculoskeletal Radiologist Doctor with extensive experience in image-guided intervention

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