The Pros and Cons of Steroid Injections for Your Shoulder Pain?

Silver bullet for shoulder pain or are steroid injections overused ?

Steroid injections for shoulder pain

It's understandable that if you’re struggling with the persistent, nagging pain of a rotator cuff tendinopathy or the sharp, limiting stiffness of a frozen shoulder (adhesive capsulitis), you’re likely searching for pain relief and flexibility. In that search, the topic of corticosteroid injections inevitably crops up on most patients radar, especially when the usual anti-inflammatories have not helped.

Touted by some as a "miracle shot" yet viewed by others with caution, steroid injections are a common medical intervention for the right patient. But what are they really, and are they the right choice for you and your shoulder problem?

So, seeing as power is knowledge, before you present at your GP asking for an injection it's good to know the good, the bad and the ugly.

Firstly, What ARE a Steroid Injections?

Don’t let the word "steroid" confuse you - there's no chance of developing a shoulder like Stallone or sprouting hair from various orafices. We’re not talking about the anabolic steroids used by bodybuilders. Corticosteroids are very powerful anti-inflammatory medications. When injected directly into your shoulder joint or the surrounding bursa or tendons, they work by rapidly reducing inflammation and suppressing the immune system's response that causes pain and swelling.

This is the core of their power— but also why they are controversial and are used judiciously.

The Pros of Steroid Injections: Powerful Benefits

1. Rapid Pain Relief: This is the most significant and immediate benefit. While oral anti-inflammatories can take time to work and physiotherapy requires a gradual approach, a steroid injection can provide noticeable pain relief within 24 to 72 hours. It's a quick win and can be a massive boost for patients in severe pain providing much needed relief.

2. Reduction of Inflammation: These injections are exceptionally effective at calming down the inflamed tissues. In a rotator cuff tendinopathy, this means soothing an irritated tendon or bursa. For a frozen shoulder, it means directly addressing the inflammatory process that triggers the joint capsule to thicken and tighten internally causing that characteristic pain and eventual stiffness.

3. Breaking the Pain-Spasm Cycle: Pain causes muscle guarding and spasm, which leads to more pain and less movement. By dramatically cutting the pain signal, the injection can break this vicious cycle, allowing your muscles to relax, restoring normal movement.

4. Creating a Window of Opportunity for Physiotherapy: THIS is, in our view, the most valuable pro - well we would say that wouldn't we ! That period of reduced pain and increased mobility in the weeks after an injection is a golden opportunity to engage effectively in physiotherapy and rehab. When pain is no longer the dominant factor, you can more comfortably and successfully perform the stretching and strengthening exercises essential for long-term recovery. For a frozen shoulder, this means being able to work on crucial range-of-motion exercises. For a rotator cuff issue, it means being able to strengthen without aggrevating and flaring up the tendon.

The Cons of Steroid Injections: Important Considerations

With every positive there comes a negative - it's the way of the world. While the benefits are compelling, it’s crucial to understand the potential downsides and risks. ALso being able to appreciate them makes it easier to understand why your doctor may chose to NOT offer an injection.

1. It’s a Mask, Not a Cure: This is the most critical point to understand. The injection addresses the symptom (inflammation and pain) but not the underlying cause. If your rotator cuff tendinopathy is due to poor posture, muscle weakness, or faulty movement patterns, the pain will almost certainly return once the steroid wears off if those issues aren't corrected.

2. Potential for Tissue Weakening: Repeated or improperly timed steroid injections can weaken tendons, ligaments, and cartilage. For a rotator cuff that may already be compromised, there is a theoretical risk of further tendon degeneration or even rupture, though this is rare with judicious use. This is a major reason why number of injections is limited

3. Short-Term Side Effects: It’s common to experience a "cortisone flare," where the injection site becomes more painful for a day or two as the corticosteroid crystallises and causes local swelling. There's also a risk of skin thinning, fat atrophy (a small dent at the injection site), or temporary elevation of blood sugar levels, particularly relevant for diabetics.

4. A False Sense of Security: Because the pain is gone, you might feel "fixed" and return to activities your shoulder isn’t ready for. Overloading a pain-free but still weak and dysfunctional tendon is a recipe for re-injury. The injection provides a window for rehab, not a free pass to resume all activities.

5. Limited Efficacy for Frozen Shoulder Stages: The effectiveness of injections for frozen shoulders is highly dependent on the stage the injection is given. They are most effective in the early, painful "freezing" stage. In the later, stiff "frozen" stage, where inflammation is less of a driver, an injection may do little to improve mobility, and a hydrodilatation procedure might be a better option ( more of that in another blog ! )

" The injection addresses the symptom (inflammation and pain) but not the underlying cause. Vitally important to appreciate "

What Makes or Breaks a Steroid Injection's Success ?

While understanding the general pros and cons is essential, the success of a steroid injection often hinges on three finer points: Accuracy of Diagnosis, Precision of the Injection, and Optimal Timing. Getting these three right is what separates a successful treatment from a disappointing one

1. The Non-Negotiable: A Correct Diagnosis

"Shoulder pain" is not a diagnosis. Injecting a shoulder without a precise diagnosis is like throwing a dart in the dark - ineffective and potentially dangerous !

• Rotator Cuff Tendinopathy vs. Frozen Shoulder: While they can co-exist, they are different conditions. A steroid injection for an inflamed subacromial bursa (common in tendinopathy) is very different from an intra-articular joint injection for a frozen shoulder. Obviously placing the medication in the wrong structure will not help the pain.

• Other Mimickers: Shoulder pain can originate from the neck (cervical radiculopathy), the acromioclavicular (AC) joint, or even be referred from other visceral organs. For example, an injection aimed at the rotator cuff will do nothing for a pinched nerve in the neck.

2. The Art and Science of Injection Technique

Not all injections are created equal. The skill of the practitioner and the guidance method used are paramount.

• Landmark vs. Image-Guided: A "landmark-guided" injection relies on feeling bony structures to estimate the needle's placement. This can be effective in experienced hands but has a higher chance of the medication being delivered into the wrong tissue (e.g., into the muscle instead of the bursa or joint).

• The Gold Standard - Ultrasound Guidance: Many specialists now use ultrasound guidance for shoulder injections. This allows the clinician to see the needle in real-time on a screen, navigating it precisely to the target area—be it the subacromial space, the glenohumeral joint, or the biceps tendon sheath. In my experience, whilst it may be preferable, in practice it isn't seen as often. Largely due to availability of US scanning machines which are not a staple piece of equipment in most GP practices.

3. The Critical Window: Has the Boat Been Missed on Timing?

Timing is everything in medicine, and steroid injections are a prime example. The question of whether the "boat has been missed" is highly relevant, especially for frozen shoulders.

• Rotator Cuff Tendinopathy: Here, the "window" is less about disease stage and more about the failure of other interventions. An injection is typically considered after a period of dedicated physiotherapy (e.g., 6-12 weeks) has failed to control pain sufficiently to allow for progression. It's shouldn't be a first-line option but a strategic intervention to overcome a plateau ( a kick up the clinical bum, so to speak ! )

Frozen Shoulder (Adhesive Capsulitis): This condition has distinct stages, and timing is absolutely critical.

• Freezing Stage (Painful Phase): This is the ideal time for an injection. The primary driver is significant inflammation, and a corticosteroid is exceptionally effective at dampening this pain, potentially slowing the progression into the frozen stage.

• Frozen Stage (Stiffness Phase): Here, the inflammatory component has lessened, and the main problem is thick, stiffened joint capsule tissue. A standard steroid injection at this stage often has diminished returns. The "boat" for using a simple steroid injection to dramatically alter the course of the condition has largely sailed. Other interventions like hydrodilatation (injecting a large volume of fluid to stretch the capsule) or more aggressive manual therapy become more relevant.

• Thawing Stage: An injection is rarely indicated here, as the body is naturally resolving the stiffness.

The Physiotherapist's Verdict on Steroid Injections: A Tool, Not a Solution

So, where does this leave you and your painful shoulder ?

Corticosteroid injections are neither a hero nor a villain. They are a powerful tool in the therapeutic toolbox..... for the right patients and conditions The decision to have one should be made collaboratively with your doctor and physiotherapist, considering your specific condition, pain levels, and stage of injury.

An injection is MOST appropriate when:

• Pain is so severe it completely prevents you from participating in physiotherapy.

• It’s used strategically to create that "window of opportunity" for active rehab. It's pointless popping in an injection and sending you on your merry way if there is no rehab to address the underlying causes.

An injection is NOT a good long-term strategy if:

• You are looking for a permanent cure without addressing the root cause. Your problem will recur

• You’ve had multiple injections in a short period.

• Your primary issue is stiffness and weakness, not acute inflammation

The Bottom Line

The way to a healthy, pain-free shoulder is rarely a single injection. A steroid injection can be a powerful ally on that journey, helping you get through the toughest part so you can do the work that leads to lasting recovery. And that means targeted rehab that addresses strength, flexibility, posture, and movement mechanics.... i'e the underlying causes of the problem in the first palce.

If you’re considering a steroid injection, speak with your physiotherapist or sports therapist. We can help you understand your condition, guide you on whether an injection might be beneficial, and most importantly, ensure you have a robust rehabilitation plan to make the most of the relief it provides. Otherwise why take the risks an injection brings without the full benefit.