Abstract
BackgroundVariations 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.Methods264 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.Results169 (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.ConclusionVariations 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.
Highlights
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
We conducted a survey by mail of orthopaedic surgeons (n = 163), rheumatologists (n = 24), and specialty physicians [PCSMs = primary-care sports medicine physicians, and PMRs = physical medicine and rehabilitation physicians ("physiatrists") (n = 77)] in Utah, Idaho, and Wyoming regarding their use of corticosteroid for painful shoulder conditions
Of the 264 surveys that were mailed, 169 usable surveys were returned (64% overall response rate) from the early responders, including 105/163 orthopaedic surgeons (64% response rate), 44/77 PCSMs/PMRs (57% response rate), and 20/ 24 rheumatologists (83% response rate)
Summary
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. Injectable corticosteroids are commonly used by orthopaedic surgeons, rheumatologists, primary-care physicians and other health-care providers in the treatment of painful shoulder conditions. 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 [2-12] (Table 1). Among these reviews, we observed that confusion often arises regarding dosing when making a direct correlation between equivalences and relative potencies of corticosteroids (Tables 2 and 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) [13]
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