Should I have a cortisone injection for my shoulder pain?

Cortisone injections for shoulder pain are common, really common. A pathway we see in the management is, GP appointment --> Ultrasound Scan --> Injection.

The problem is, in a lot of these cases, patients then present to physiotherapy still in pain, and understandably frustrated. Often the medical advice they have been given in these circumstances is that they should try another round of cortisone. So what should you do? One of the most common questions we get in clinic from our patients is whether or not they should get a cortisone injection for their shoulder pain (or knee pain, or back pain, for that matter). Most often, the answer from us here at Out of the Box Physiotherapy is “Perhaps’. But we need to look at what has been done so far and whether or not an injection is indicated will depend on a number of factors, some of the major ones are?

1. Do we have a diagnosis or at least an idea as to what structure (or structures) might be causing the shoulder pain? If not, then we need to know this before proceeding.
There are several structures all really close together around the shoulder and this means that identifying a specific structure or source is difficult. We have tests that can identify movements that cause pain and these can give us an idea on the type of shoulder dysfunction that is present but often we need to treat the shoulder holistically as a whole complex rather than just trying to fix a specific tendon or bursa.

2. Is the pain coming from an inflammatory source? If not, then cortisone is unlikely to have an effect.
If the only pathology found on imaging is an inflamed bursa in the shoulder, then injection of corticosteroid may have an effect on pain and function

3. Have oral anti-inflammatories been trialled? What effect did they have?
If oral NSAIDS did not have an effect we should possibly question the effect that cortisone (which is also an anti-inflammatory) might have?

4. What treatment and exercises have been used so far in the management of shoulder pain?
Have we loaded the shoulder properly in trying to rehabilitate it, have we taken away painful impingement movements and worked on strengthening the scapular and rotator cuff complex?

5. How long has physiotherapy or other treatments been trialled for?
Research has shown similar outcomes for patients at 12 weeks with either injection, physiotherapy, or injection and physiotherapy

The challenge with treating shoulder pain is that in a lot of cases, there are multiple structures that might be causing the shoulder to be sore. Structures such as the sub-acromial or sub-deltoid bursa might be inflamed, but there could also be some changes in the rotator cuff tendons as well, and some arthritis in the AC joint. Rarely in shoulder pain cases do we see only one of these structures involved so the best course of treatment is physiotherapy, with some initial hands on treatment if required to restore balance and then treatment needs to focus on exercise-based management to improve shoulder strength and function. This needs to be done progressively and over the course of 3-6 months. So the answer to the question, Should I have a cortisone injection for my shoulder pain? Ultimately it is up to you, the patient to decide. There is not a lot to lose from having one, but our experience also tells us that in a lot of cases there is also not a lot to gain. Hopefully the answers to some of the points above help you to make a decision and we are more than happy to discuss your shoulder pain with you further and we will always provide you with the most honest advice we can. Those patients that get the best outcomes, in our opinion, are those that work on improving the mechanics of their shoulder and whole upper body and take their time to do this well.