Variations in Corticosteroid/Anesthetic Injections for Painful Shoulder
Variations in Corticosteroid/Anesthetic Injections for Painful Shoulder
Background: Variations in corticosteroid/anesthetic doses for injecting shoulder conditions were examined among orthopaedic surgeons, rheumatologists, and primary-care sports medicine (PCSMs) and physical medicine and rehabilitation (PMRs) physicians to provide data needed for documenting inter-group differences for establishing uniform injection guidelines.
Methods: 264 surveys, sent to these physicians in our tri-state area of the western United States, addressed corticosteroid/anesthetic doses and types used for subacromial impingement, degenerative glenohumeral and acromioclavicular arthritis, biceps tendinitis, and peri-scapular trigger points. They were asked about preferences regarding: 1) fluorinated vs. non-fluorinated corticosteroids, 2) acetate vs. phosphate types, 3) patient age, and 4) adjustments for special considerations including young athletes and diabetics.
Results: 169 (64% response rate, RR) surveys were returned: 105/163 orthopaedic surgeons (64%RR), 44/77 PCSMs/PMRs (57%RR), 20/24 rheumatologists (83%RR). Although corticosteroid doses do not differ significantly between specialties (p > 0.3), anesthetic volumes show broad variations, with surgeons using larger volumes. Although 29% of PCSMs/PMRs, 44% rheumatologists, and 41% surgeons exceed "recommended" doses for the acromioclavicular joint, > 98% were within recommendations for the subacromial bursa and glenohumeral joint. Depo-Medrol(methylprednisolone acetate) and Kenalog(triamcinolone acetonide) are most commonly used. More rheumatologists (80%) were aware that there are acetate and phosphate types of corticosteroids as compared to PCSMs/PMRs (76%) and orthopaedists (60%). However, relatively fewer rheumatologists (25%) than PCSMs/PMRs (32%) or orthopaedists (32%) knew that phosphate types are more soluble. Fluorinated corticosteroids, which can be deleterious to soft tissues, were used with these frequencies for the biceps sheath: 17% rheumatologists, 8% PCSMs/PMRs, 37% orthopaedists. Nearly 85% use the same non-fluorinated corticosteroid for all injections; < 10% make adjustments for diabetic patients.
Conclusion: Variations between specialists in anesthetic doses suggest that surgeons (who use significantly larger volumes) emphasize determining the percentage of pain attributable to the injected region. Alternatively, this might reflect a more profound knowledge that non-surgeons specialists have of the potentially adverse cardiovascular effects of these agents. Variations between these specialists in corticosteroid/anesthetic doses and/or types, and their use in some special situations (e.g., diabetics), bespeak the need for additional investigations aimed at establishing uniform injection guidelines, and for identifying knowledge deficiencies that warrant advanced education.
Injectable corticosteroids are commonly used by orthopaedic surgeons, rheumatologists, primary-care physicians and other health-care providers in the treatment of painful shoulder conditions. However, surveys have estimated that 60% to 70% of internists finishing their residency training feel that they need more training in performing these injections. Furthermore, even though corticosteroid injections are commonly used for painful shoulder conditions, there are no uniform guidelines regarding dosage and other aspects of their administration. In order to work towards this goal, baseline information regarding corticosteroid usage is needed. We were not able to locate published data comparing and contrasting surgeon and non-surgeon musculoskeletal specialists who treat painful shoulder conditions with these injections. Additionally, our literature review of studies (including meta-analyses) evaluating the use of corticosteroid injections for painful shoulder conditions show a lack of consensus regarding their dosing and time course of administration ( Table 1 ). Among these reviews, we also observed that confusion often arises regarding dosing when making a direct correlation between equivalences and relative potencies of corticosteroids ( Table 2 and Table 3 ). This lack of uniform injection guidelines is important because deleterious consequences and other sequelae, both systemic and local, can result from corticosteroid injections, especially from chronic use, large doses, and errant injection (e.g., into a tendon).
The goal of this study is to evaluate current trends of injectable corticosteroid use among orthopaedic surgeons and selected non-surgeon sub-specialists and specialty physicians (rheumatologists, primary-care sports medicine physicians, and physical medicine and rehabilitation physicians) for injecting degenerative and overuse shoulder conditions in order to provide data that will ultimately be needed to establish uniform guidelines and identify potential knowledge deficiencies. We focused on these physicians in our tri-state referral area (Utah, Idaho, Wyoming; population = ~4.5 million people) in the western United States. We hypothesize that: 1) there are significant differences in types and doses of corticosteroid and local anesthetic used for shoulder injections within and between surgical and non-surgical specialists who treat various painful shoulder conditions, and 2) doses of corticosteroid and local anesthetic administered in shoulder injections often fall outside presently recommended ranges. Additional considerations included questions regarding: 1) the use of fluorinated vs non-fluorinated corticosteroids, 2) the use of acetate vs. phosphate types, 3) the rationale for using a particular corticosteroid, 4) adjustments regarding patient age, and 5) adjustments for special considerations including young athletes and diabetics.
Background: Variations in corticosteroid/anesthetic doses for injecting shoulder conditions were examined among orthopaedic surgeons, rheumatologists, and primary-care sports medicine (PCSMs) and physical medicine and rehabilitation (PMRs) physicians to provide data needed for documenting inter-group differences for establishing uniform injection guidelines.
Methods: 264 surveys, sent to these physicians in our tri-state area of the western United States, addressed corticosteroid/anesthetic doses and types used for subacromial impingement, degenerative glenohumeral and acromioclavicular arthritis, biceps tendinitis, and peri-scapular trigger points. They were asked about preferences regarding: 1) fluorinated vs. non-fluorinated corticosteroids, 2) acetate vs. phosphate types, 3) patient age, and 4) adjustments for special considerations including young athletes and diabetics.
Results: 169 (64% response rate, RR) surveys were returned: 105/163 orthopaedic surgeons (64%RR), 44/77 PCSMs/PMRs (57%RR), 20/24 rheumatologists (83%RR). Although corticosteroid doses do not differ significantly between specialties (p > 0.3), anesthetic volumes show broad variations, with surgeons using larger volumes. Although 29% of PCSMs/PMRs, 44% rheumatologists, and 41% surgeons exceed "recommended" doses for the acromioclavicular joint, > 98% were within recommendations for the subacromial bursa and glenohumeral joint. Depo-Medrol(methylprednisolone acetate) and Kenalog(triamcinolone acetonide) are most commonly used. More rheumatologists (80%) were aware that there are acetate and phosphate types of corticosteroids as compared to PCSMs/PMRs (76%) and orthopaedists (60%). However, relatively fewer rheumatologists (25%) than PCSMs/PMRs (32%) or orthopaedists (32%) knew that phosphate types are more soluble. Fluorinated corticosteroids, which can be deleterious to soft tissues, were used with these frequencies for the biceps sheath: 17% rheumatologists, 8% PCSMs/PMRs, 37% orthopaedists. Nearly 85% use the same non-fluorinated corticosteroid for all injections; < 10% make adjustments for diabetic patients.
Conclusion: Variations between specialists in anesthetic doses suggest that surgeons (who use significantly larger volumes) emphasize determining the percentage of pain attributable to the injected region. Alternatively, this might reflect a more profound knowledge that non-surgeons specialists have of the potentially adverse cardiovascular effects of these agents. Variations between these specialists in corticosteroid/anesthetic doses and/or types, and their use in some special situations (e.g., diabetics), bespeak the need for additional investigations aimed at establishing uniform injection guidelines, and for identifying knowledge deficiencies that warrant advanced education.
Injectable corticosteroids are commonly used by orthopaedic surgeons, rheumatologists, primary-care physicians and other health-care providers in the treatment of painful shoulder conditions. However, surveys have estimated that 60% to 70% of internists finishing their residency training feel that they need more training in performing these injections. Furthermore, even though corticosteroid injections are commonly used for painful shoulder conditions, there are no uniform guidelines regarding dosage and other aspects of their administration. In order to work towards this goal, baseline information regarding corticosteroid usage is needed. We were not able to locate published data comparing and contrasting surgeon and non-surgeon musculoskeletal specialists who treat painful shoulder conditions with these injections. Additionally, our literature review of studies (including meta-analyses) evaluating the use of corticosteroid injections for painful shoulder conditions show a lack of consensus regarding their dosing and time course of administration ( Table 1 ). Among these reviews, we also observed that confusion often arises regarding dosing when making a direct correlation between equivalences and relative potencies of corticosteroids ( Table 2 and Table 3 ). This lack of uniform injection guidelines is important because deleterious consequences and other sequelae, both systemic and local, can result from corticosteroid injections, especially from chronic use, large doses, and errant injection (e.g., into a tendon).
The goal of this study is to evaluate current trends of injectable corticosteroid use among orthopaedic surgeons and selected non-surgeon sub-specialists and specialty physicians (rheumatologists, primary-care sports medicine physicians, and physical medicine and rehabilitation physicians) for injecting degenerative and overuse shoulder conditions in order to provide data that will ultimately be needed to establish uniform guidelines and identify potential knowledge deficiencies. We focused on these physicians in our tri-state referral area (Utah, Idaho, Wyoming; population = ~4.5 million people) in the western United States. We hypothesize that: 1) there are significant differences in types and doses of corticosteroid and local anesthetic used for shoulder injections within and between surgical and non-surgical specialists who treat various painful shoulder conditions, and 2) doses of corticosteroid and local anesthetic administered in shoulder injections often fall outside presently recommended ranges. Additional considerations included questions regarding: 1) the use of fluorinated vs non-fluorinated corticosteroids, 2) the use of acetate vs. phosphate types, 3) the rationale for using a particular corticosteroid, 4) adjustments regarding patient age, and 5) adjustments for special considerations including young athletes and diabetics.
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