One of the most common questions I encounter throughout a typical day in the office is whether or not steroid or “cortisone” injections are harmful. Patients are often rightfully concerned about the possible side effects of what we as physicians are so routinely injecting around various joints and tendons throughout the body. Unfortunately, the answer to this question, as is frequently the case in medicine, is “well, it depends…” While that may not be a particularly satisfying answer, there are some definite conclusions that we can make.
In this case, it depends on the underlying diagnosis that is being treated with injections. While there are some concerns about the effect of local anesthetic that is often mixed with steroids for an injection, we can generally assume that these injections are a safe and effective for treatment of shoulder osteoarthritis. These injections may temporarily elevate blood sugar in some diabetic patients, but otherwise are typically free from many of the side effects associated with long term use of oral steroids. The risk of infection is exceptionally low and the pain relief quite predictable. The use of steroid injections for treatment of pain associated with rotator cuff tears is much more controversial, however.
Numerous prior studies have reported on the possible adverse effects of steroid injections on the health and integrity of rotator cuff tissue. Surgeons have long had concerns that these injections might have a deleterious effect on healing rates of subsequent rotator cuff repair surgery. Fortunately, we now have more information to help guide surgeons and patients in deciding if, when, and how many steroid injections might be appropriate in managing the pain associated with a rotator cuff tear. Three separate studies have been published in the journal Arthroscopy earlier this year seeking to answer the question of whether or not steroid injections are associated with poorer outcomes after rotator cuff surgery.1-3 In each of these studies, there was a clear association between the number and timing of steroid injections and subsequent failed rotator cuff repair surgery. In general, 2 injections before surgery and injections within 6 months to a year before surgery were associated with a significantly increased risk of needing a revision rotator cuff repair surgery. This association alone does not necessarily establish a cause and effect relationship (it could be that injections were given to patients with bigger tears and a worse prognosis already), but at a minimum it should raise some concerns about injections in this setting, particularly in patients considering future surgical treatment.
From these studies, we can gather that steroid injections appear to pose a legitimate risk to the rates of healing after rotator cuff surgery. Talk to your surgeon about the risks of injections if you are receiving them for management of pain associated with a rotator cuff tear. Consideration should be given to minimizing the number of injections before surgery to one at most and to avoiding injections altogether within six months of a planned rotator cuff repair.
Dr. Kevin Harreld is a board certified orthopedic surgeon specializing in shoulder and elbow surgery. His areas of clinical interest include rotator cuff injuries, shoulder instability, and shoulder replacement.
- Desai et al. Increasing numbers of shoulder corticosteroid injections within a year preoperatively may be associated with a higher rate of subsequent revision rotator cuff surgery. Arthroscopy. 2019 Jan; 35(1):45-50
- Traven et al. Preoperative shoulder injections are associated with increased risk of revision rotator cuff repair. Arthroscopy. 2019 Mar; 35(3):706-13
- Weber et al. Injections prior to rotator cuff repair are associated with increased rotator cuff revision rates. Arthroscopy. 2019 Mar; 35(3):717-24