Do you need a cortisone shot?

I presented this article at our recent Rheumatology journal club: “Exercise therapy after corticosteroid injection for moderate to severe shoulder pain: large pragmatic randomised trial” from BMJ (2010).

It is available full text via the link above. In a nutshell, this was a study of 232 people over 40 with unilateral shoulder pain. People with prior  surgery or underlying conditions such as prior surgery or known arthritic conditions like RA were excluded (along with several other exclusion criteria). Patients were randomized into steroid injection (20mg triamcinolone) AND physical therapy or physical therapy only. Response was assessed at weeks 1, 6, 12 and 24. From the article text:

What is already known on this topic

  • Shoulder pain is common, persistent, and often caused by subacromial impingement syndrome

  • Exercise, manual therapy, and corticosteroid injections are common interventions in primary care for this condition

What this study adds

  • Steroid injection combined with exercise is of similar effectiveness to exercise only at 12 weeks

  • A third of patients treated with exercise and manual therapy alone do not improve sufficiently by 12 weeks and will opt for a steroid injection

  • Earlier improvement in pain and function is seen with corticosteroid injection combined with exercise and manual therapy

Will this change how patients with shoulder pain are treated? Probably not, but it is reinforcement of what we do typically see in practice – shoulder pain usually improves by 3 months whether you get a steroid shot or do PT, but it will improve faster with an injection. However, there are complications to injections so if patients are nervous about that, needle phobic or just willing to do a course of PT then there certainly is not a need to absolutely do an injection. There was no arm of people who JUST did an injection and didn’t do PT (which is probably the more likely scenario for people who get injections) and I’d like to know how they compared with the other groups. Thoughts?

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4 responses to “Do you need a cortisone shot?

  1. I am an advocate for physiotherapy, with or without cortisone injection (disclosure: I perform these injections like all rheumatologists).

    Apart from the exercise & manual therapy, a good physiotherapist can actually look at the biomechanics of the shoulder joints, how the scapula interacts, etc. This unfortunately is often neglected.

    To help prevent recurrent and/or progressive shoulder problems, an attempt to improve these biomechanics is important.

  2. PT is great, but expensive and time consuming. Many people can’t get time off work 2-3 times a week to go to PT, even if they can afford it. I have to meet my $1500 deductible before insurance will start paying 80% of the cost of PT, so at $150 per session, six weeks of PT (twice a week) will be $1560 out of my pocket. There’s also a limit of 15 PT sessions per year, so insurance won’t really cover a second round of PT (for instance, when I was referred one year for my hips and then later for my shoulders).

    Steroid injections, on the other hand, are $134 from my family doctor, or $172 from my rheumatologist, or $269 from my orthopedist. After I’ve met my deductible, insurance will cover 80%.

    My choices, then, are between $134 to my family doctor and feel enough better in a few days that I can do some exercises at home, or $1560 to the PT and finding time to make two appointments a week for a month and a half – and still need to do the exercises at home, too.

    I’m a big fan of how much PT can help. As much as it costs, though, I just can’t afford it any more.

  3. Karen Daugherty

    Going through PT now for bilateral achilles tendonitis which appears to be related to my RA. Although physical therapy has helped a great deal, I don’t think I would have been able to tolerate it without the steroid injections. As a previous poster notes, PT is very expensive and not easy to schedule. I managed the cost more easily now that I’ve met my maximum out of pocket for the year, but arranging appointments around work is not easy. Not being able to walk normally wasn’t particularly convenient, either, though. Just sayin’.

  4. Claire Mccluney

    Shoulder pain can easily be reduced by using a light massage. Some herbal oils can also reduce the pain and inflammation. *’.:,

    Latest article content on our very own homepage
    http://www.healthmedicinelab.com/sma-syndrome/

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