Doc, I just need a shot in my shoulder and I’ll be good to go.
Steroid (cortisone) injections have been Orthopaedic surgeon’s favorite arrow in the quiver for decades. Steroids are a potent anti-inflammatory that is typically used to rapidly reduce painful symptoms that accompany inflammation and arthritis from both acute injuries and chronic degeneration. Steroids are typically included in the first line of treatment for a variety of musculoskeletal conditions due to their strong clinical efficacy, low-cost, and minimal side effects.
However, recent research has begun to suggest that the steroid panacea may not be as simple as we once thought. Within the shoulder, inflammation has long been believed to be the principle driver of pain related to rotator cuff pathology. Hence, common treatment strategies revolved around administering a corticosteroid injection to directly counteract this inflammation, relieve pain, and allow the patient to more meaningfully participate in therapy and home exercise. However, an increasing body of basic science literature has begun to suggest that the inflammation caused by rotator cuff pathology is part of larger failed healing response and chronic injury. Furthermore, inflammation is a small, albeit extremely important, part of a much larger process that occurs as part of the body’s healing response. The healing of any tendon, ligament, or bony injury requires several complex phases including inflammation, proliferation of new cells including blood vessels and nerve innervation, and remodeling. While inflammation is painful, it is necessary for essential cell signaling and communication to ensure complete healing.
Understanding this, we have a basic science rationale for how a potent anti-inflammatory, like corticosteroids, might disrupt our natural healing process. For example, the painful inflammation that occurs when we have a rotator cuff tear or tendonitis is our body’s attempt to promote healing, and while a steroid reduces the pain from the inflammation, it also halts our own ability to downregulate inflammation and heal damaged tissue. While these pathways have been well researched and known for long periods of time, it is not until relatively recently that researchers began to specifically study how steroid injections may negatively effect procedures that rely on tendon to bone healing, such as rotator cuff repair. When a patient undergoes arthroscopic rotator cuff repair, the goal of the surgery is to achieve complete tendon to bone healing. As a surgeon, we are attempting to invoke a healing response, which, as stated before, requires an inflammatory response. Increasing steroid injections closer to the time of surgery might interfere with this response and make it harder for complete healing to occur. In fact, multiple animal and human studies have shown exactly this, a negative relationship with both the timing and frequency of steroid injections prior to undergoing rotator cuff repair with repair failure, need for revision surgery, and infectious complications.
Despite the mounting basic science and clinical evidence that steroid injections do in fact have a detrimental impact on tendon to bone healing and tissue remodeling, I personally do not think it is time to rethink our conservative treatment algorithms of shoulder pain related to rotator cuff pathology. Furthermore, patients and surgeons should make a shared decision on whether a steroid injection is appropriate for the specific injury and condition being treated that is in alignment with the patient’s functional goals and demands. Despite the evidence presented, success rates and clinical satisfaction after rotator cuff surgery remain exceedingly high, and injections are just but one of several factors associated with dissatisfaction and retear when it occurs. Steroid injections remain safe and simple treatments that can be used to delay and circumvent surgery. However, if a patient fails to obtain durable and effective relief from a steroid injection with reliable therapy, I do not agree with performing additional injections. Repeated exposures have clearly been correlated with harmful effects that are detrimental to healing.
Finally, if inflammation is a painful part of a necessary healing process, is there anything else we can do to relieve this pain while not disrupting this process? If you are asking yourself this question you are certainly on the right website and have arrived at the right surgeon. Dr. Chahla is a pioneer in exactly this, harnessing our body’s natural healing responses and processes to relieve pain and improve function. His investigations into PRP and BMAC seek to identify and isolate our body’s own growth factors to downregulate inflammation and relieve pain while stimulating our healing response.
In closing, while I do not believe it is time to do away with steroid injections for shoulder pathology, it is important for patient’s and surgeons alike to carefully consider the short-term benefits with the longer term risks and its effects on our patient’s desired final outcome.
About the author
Jourdan M. Cancienne, MD
Southern Orthopaedic Specialists
New Orleans, LA
Instagram • @nolasportsdoc
Dr. Cancienne attended Catholic High School in Baton Rouge, LA and then attended Tufts University where he was awarded all conference and academic 1st team honors on the football team. He then returned home to Tulane University School of Medicine before completing his orthopaedic surgery training at the University of Virginia. During his time in Charlottesville, VA, Dr. Cancienne received recognition as the resident of the year and won several regional and national awards for his research. He was then selected to receive advanced specialized training in shoulder surgery, sports medicine, and cartilage restoration at Midwest Orthopaedics at Rush in Chicago. During this time in Chicago, he served as a team physician for the Chicago White Sox, Chicago Bulls, Chicago Steel, and Chicago Fire.
In addition to patient care, Dr. Cancienne maintains a significant interest in clinical research in order to develop and perfect treatment strategies that allow for earlier and more complete recovery for patients of all activity levels. He has published over 100 peer reviewed articles and book chapters on a wide variety of Orthopaedic topics and has presented his research both nationally and internationally over 200 times. His recent research has incorporated the application of biologic therapies to augment healing in both operative and non-operative settings. He is also involved in multiple orthopaedic sports medicine societies such as the American Orthopaedic Society for Sports Medicine, the Arthroscopy Association of North America, and the American Academy of Orthopaedic Surgeons.
As an advocate for education, research, and patient care, Dr. Cancienne remains dedicated to returning patients back to their desired activity level regardless of their level of participation. His teams’ approach is to provide the highest level of clinical care to ensure excellent patient outcomes and satisfaction.