To Inject or Not Inject the Shoulder, That is the Question

Patients often ask me when it’s appropriate to have a shoulder injection. Like any treatment plan, conservative measures are implemented prior to more aggressive intervention and the utilization of the shoulder injection can actually be used in many phases of the treatment progression. The patient should feel comfortable with this progression of procedural care via the prior communication of short and long term goals by both physician and therapist, thus appreciating that at times an injection is a vehicle that will speed the recovery process.

Factors to Consider

Ultimately it is the physician’s decision whether to utilize a shoulder injection. There are many underlying factors that determine whether an injection is appropriate, including:

• level of soft tissue injury in/about the shoulder joint
• underlying systemic health issues
• prior injections to the same shoulder

The location of the injection may change as well. It is easy to inject underneath the bony roof of the shoulder via a posterior approach (you don’t have to watch either), a site where pain originating from bursal pain or arthritic change in and about where the collar bone and shoulder blade attach. This procedure may be repeated months later if it is not effective the first time noting that the implementation of physical therapy following a first injection is historically quite successful. A second injection may be necessary with more chronic/severe shoulder cases and will hasten the progress of the physical therapy care in conjunction with the goal of pain relief.

Ultrasound

With progressions in diagnostic imaging, the use of ultrasound to identify, locate and guide injections to pathologic tissue has become a highly utilized tool in the physician’s office. This saves a trip to the radiology specialist to perform similar procedures using fluoroscopy (a dynamic x-ray). Not only can the treating physician (who is the most familiar with the joint) now administer the injectable, this also eliminates the need to be exposed to another x-ray. With this technology, it is now possible to inject the conduit housing of the biceps tendon and the ball and socket joint, both of which are common pain generators.

I am fortunate enough to have developed professional relationships with highly competent shoulder physicians across the Twin Cities Metro and Mayo Clinic. With their high volume of cases loads, the appropriate plan of care flows in near algorithmic progression. Approximately 80% of all shoulder cases can be (this is dependent on the experience/quality of the patients provider) solved in a non-surgical fashion and the orthopedic shoulder specialist will send the appropriate patient to physical therapy to implement a rehab program that fits their underlying joint status and symptoms.

Physical Therapy Perspective

From a physical therapy perspective, my goal with this type of patient is to resolve 33% to 50% of pain symptoms in 3 to 6 weeks from the start of care. If this is accomplished, the majority of symptoms can generally be resolved with a regimented physical therapy program and diligent patient effort regarding their pre-established goal progressions.

If ongoing pain symptoms prevent normative sleep patterns and are highly distracting during one’s normal day (i.e. >5/10 on a 0-10 pain scale) and the physician has authorized an injection, it is viable to proceed in this fashion. The patient always has the final choice, obviously needing to be tolerant to such a procedure.

Accompanying Mechanical Changes

I always convey a word of caution to the patient that an injection is “similar to turning up the radio when you have a bad muffler.”  There has to be accompanying mechanical change via physical therapy care and the patient’s home exercise program to resolve the origin of the pain symptoms. If the patient falls to the temptation to do something more aggressive than what the now pain free but still mechanically compromised shoulder can do, there will be an inevitable flare up and subsequent compromise of one’s overall progress.

Like any other tool, if used properly and in a timely fashion, a shoulder injection can play a very positive role in ones return to more normative shoulder function.