Troubleshooting Cortisone for Shoulder Pain

When it comes to shoulder pain, two of the leading management options are physiotherapy and cortisone (steroid) injections. However, there is a lot of debate whether one is better than the other, or if there are any actual benefits to getting a steroid injection. Naturally, this has led to lots of questions and confusion about the best path to take.

As a physio, of course I am biased to recommend my own profession as a first-line treatment. But I will do my best to give you an unbiased breakdown of the latest research so you can make your own educated opinion.

DISCLAIMER: There are a lot of factors involved with whether or not a treatment will work for you - what works for some does not work for all. So please take the information below with a grain of salt.

First off - Cortisone is used to treat inflammation

So if your pain is not being caused or aggravated by an inflammatory process, you may not find relief with cortisone.

The way cortisone works is that is alleviates inflammation within the shoulder complex. For best results, the needle is guided by a CT-scan or ultrasound into the either the joint (intra-articular injection) or tendon (tendon injection). It does not necessarily solve the problem, but rather provides a window of relief. Now for some, this break is enough to calm the shoulder down and allow for healing - which means they may remain pain-free even after the injection wears off. For others whose pain is caused by inflammation due to repetitive use or compression of structures within the shoulder, this window may only be short lived. In the case of subacromial pain syndrome, this window can last between 3 to 38 weeks. One study found that, for rotator cuff tendinopathies, improvements in pain could be maintained for up to 9 months.

What is the best time to get an injection?

Pain that is acute or subacute (i.e. 1-12 weeks since the onset of pain) typically responds well to intra-articular cortisone injections. However, if you have a chronic condition, the effectiveness of cortisone reduces. This may be due to the adaptive changes that occur within the body when it has experienced pain past the expected healing timeframes for soft tissues and bone. We look into these changes more within our previous blog posts on pain science if you are interested.

Physio vs. Cortisone

A question that has been extensively researched and debated.

Both physiotherapy and intra-articular cortisone injections are beneficial in treating shoulder pain within the short-term.

• A Cochrane review in 2003 found that cortisone may be more beneficial for frozen shoulder in the short-term than physiotherapy or a “wait and see” approach. However, these benefits were only for a short-term period, as cortisone what shown to have no significant long-term effect on frozen shoulder.

• For rotator cuff and subacromial pain, both cortisone and physiotherapy showed equal improvements in pain over a short-term period. However, physiotherapy may have better outcomes in terms of functional improvement when compared to cortisone injection.

• For rotator cuff tendinopathy, cortisone injections were more effective than physiotherapy in the short-term, however had the same benefits as taking non-steroidal anti-inflammatory medication (e.g. nurofen, ibuprofen).

When it comes to long-term benefit, physiotherapy and exercise-based rehab have been proven to have the best results for acute through to chronic shoulder pain. By focusing on strength and control of the muscles supporting the shoulder, exercise can alleviate shoulder pain by:

1. Helping you to find better movement strategies while your shoulder begins to recover

2. Increasing muscular strength for better support of the shoulder complex

3. Gradually loading the tendons of the shoulder to promote healing without compromising tendon health

4. Offloading the structures within the shoulder’s subacromial space

Is there a downside to Cortisone?

You’ll find this answer can vary depending who you ask. There is a significant amount of evidence demonstrating the negative effects that cortisone injections can have on tendon health. Cortisone injections for tendon injuries has been shown to decrease cellular proliferation and alter collagen production. These changes can lead to an acceleration of degenerative changes within the tendon, making it less stretchable and more prone to injury or possible tearing. As a result, many health professionals will advise against cortisone injections into tendons, and us physios are strong advocates for physiotherapy-led treatment for any tendon-related shoulder pain.

I’ve had one injection, but it didn’t work. Do I get another?

There is no evidence to support multiple injections having any more benefit than a single injection.

If I’ve had a rotator cuff repair, will cortisone still work?

A study in 2018 recommended that anyone considering a rotator cuff repair should not have a cortisone injection within 6 months of the operation, as it increases there risk of needing a reoperation within the following 3 years.

The bottom line

Shoulders can be tricky, and the more research we do the more evident it is that we have yet to fully understand how to best approach treatment. Both physiotherapy and intra-articular corticosteroid injections are similarly effective in reducing pain and improving function in people with shoulder pain in the short term. When it comes to chronic shoulder pain, cortisone is less effective at alleviating pain. But if you are planning on getting an injection, it is best to utilise the window of relief it gives you to focus on fixing the reasons the pain began in the first place.

A physiotherapist can help you to fully assess your condition and help you figure out the cause or contributors to your pain. From there, your physio can work with you to develop a management plan, which will include individualised exercises to strengthen and hands-on techniques to help you feel better, sooner.

References

1. Traven, S., Brinton, D., Simpson, K., Adkins, Z., Althoff, A., Palsis, J. A., & Slone, H. (2018). Shoulder Injection Prior to Rotator Cuff Repair is Associated with Increased Risk of Subsequent Surgery. Orthopaedic Journal of Sports Medicine, 6(7 suppl4), 2325967118S00171. https://doi.org/10.1177/2325967118S00171

2. Buchbinder R., Green S., & Youd J.M. (2003). Corticosteroid injections for shoulder pain. Cochrane Database of Systematic Reviews, 10.1002/14651858.CD004016. https://doi.org//10.1002/14651858.CD004016

3. Gaujoux-Viala C, Dougados M, Gossec L. (2009). Efficacy and safety of steroid injections for shoulder and elbow tendonitis: a meta-analysis of randomised controlled trials. Annals of the Rheumatic Diseases, http://dx.doi.org/10.1136/ard.2008.099572

4. Arroll, B., & Goodyear-Smith, F. (2005). Corticosteroid injections for painful shoulder: a meta-analysis. The British journal of general practice : the journal of the Royal College of General Practitioners, 55(512), 224–228.

5. Arslan S, Celiker R. Comparison of the efficacy of local corticosteroid injection and physical therapy for the treatment of adhesive capsulitis. Rheumatol Int. 2001 Sep;21(1):20-3. doi: 10.1007/s002960100127. PMID: 11678298.