Hand surgeon Steven Goldberg, MD, answers your questions about steroid injections.
Steroid injections are a common non-operative treatment for multiple musculoskeletal conditions. The following are a list of some conditions where steroid injections may be recommended:
- Carpal tunnel syndrome
- Trigger finger
- DeQuervain’s tendonitis (pain at the wrist near the base of thumb)
- Joint synovitis or arthritis
- Tennis elbow (lateral epicondylitis)
- Golfer’s elbow (medial epicondylitis)
- Shoulder bursitis
How do steroids work?
There are different types of steroids. Glucocorticoid steroids are the ones used to treat the musculoskeletal problems listed above. There are many different types of steroids that have different onsets of action, duration, solubility, and reasons for use. Any single medication may be used at different doses and volumes depending on the clinical problem. There is no single steroid regimen that is “best”. They have different effects on many different types of tissue, but they may work to reduce inflammation and change the array of proteins that cells make.
Are steroids helpful?
Steroid are often able to reduce or eliminate symptoms. They may be more effective when the disorder is less severe. When a single dose does not cure the problem, additional doses could be considered. For many of the conditions the majority of patients will have at least a temporary or partial improvement. Since the injection is less painful and less invasive than surgery and has a lower overall risk, they are often useful to try.
What are some side effects?
Minor side effects can occur and are often rare. Injection site pain may occur and last for 3 days. Bruising and swelling may occur as well. In diabetics, elevated blood sugar may occur and last for 3-5 days. In most cases the elevation is mild and does not require treatment. However, if the blood sugar is higher than normal and you are uncertain what to do, contact the health care provider who manages your diabetes. Skin hypopigmentation (a localized whiter area of skin in area where injection was given) and fat atrophy could occur several weeks to months after injection and may resolve spontaneously after a year.
What is I “pass out” or faint?
It is fairly common for someone to faint during or after an injection due to a common vasovagal reaction where the heart rate slows down and the blood pressure drops. This is accompanied by sweating, skin pallor, clamminess, loss of consciousness. You will usually awake very quickly and you may be monitored until you feel more normal. If you are not already laying down it can help to lay down, lower your head, and elevate your legs to get more blood flow to your brain. A cool rag can be placed on your forehead and sometimes a drink can help you feel better. This is not an allergic reaction and does not typically require further medical evaluation. Your health care provider may check your blood pressure, pulse, and/or blood sugar if this occurs. If they are concerned there is more to your symptoms or condition, you may be suggested to go to the emergency room or see your primary care provider.
Can I have oral steroid pills instead of an injection?
Oral steroids must be absorbed by your gastrointestinal system and then are distributed throughout your body. This means the dose you are given is much higher than what is given with an injection directly into the problem area. Thus, side effects may be higher with oral steroids, and they may be less effective. For each problem and situation, your health care provider can explain reasoning for oral vs. injectable steroids.
What should I expect if I choose to receive an injection?
Steroids are usually given in the office setting. There are multiple different ways someone may give a steroid injection. Many times the steroid will be mixed with local anesthetic. Typically, after you discuss risks and benefits of the steroid injection as compared to other treatments and possibly sign a consent, your health care provider will cleanse the skin. You may be offered a topical spray that cools the skin, but recent studies suggest this does not reduce pain. You can receive the injection either sitting or laying down. A thin needle attached to a syringe will be used to deliver the medication deep to the skin. Most doctors will use a single puncture to deliver a mixture of both medications, but some may do the injections separately. Depending on which structure is causing symptoms, the depth of the needle may vary. It may be necessary to touch the bone. After the needle is withdrawn, gentle pressure may be applied to distribute the medication and reduce bleeding or swelling. A bandage may be applied to cover the puncture site.
What should I do after my injection?
Most of the time the bandage can be removed later that day. The puncture site should be monitored for redness or drainage for several days. It is common to have minor tenderness, swelling, or a little redness. Local measures can be tried for comfort such as ice, gentle massage, or acetaminophen or a non-steroidal anti-inflammatory medication. Notify your health care provider if severe, progressive pain or swelling associated with limited motion or fever occurs, as this could be an infection. Infections are extremely rare, but if present may require a repeat evaluation and additional treatment.
When should I feel better?
Typically, improvement could occur within a few days to a few weeks. For each specific condition and based on severity and duration of your symptoms, your health care provider will estimate what you can expect. You may be given a definite follow-up visit to discuss the results of the procedure or asked to return only if you are not satisfied with the outcome.
When should my health care provider use steroid injections?
Your health care provider may discuss multiple treatments with you such as splints or other orthotics, oral medications, steroid injections, therapy, activity modification, or surgery. Steroid injections may be advised at different times in your care based on prior treatments and symptom severity. The success of injections may be higher when given earlier after symptom onset. For, example if carpal tunnel symptoms such as numbness in the thumb, index, or middle fingers comes and goes only at night and has no thumb weakness for 3 weeks, you may get a better result with an injection than someone who has constant night and day numbness for a year with inability to lift the thumb away from the palm.
How many injections can I receive and how often?
There is no exact number of maximum injections or number of days until you can receive a second injection. Advice may vary based on severity of the problem, how likely you may improve, risks of other treatments, and prior injection response. It is common for your health care provider to have certain guidelines about number of injections and time between them based on their experience. With a higher number of injections administered frequently into the same site, side effects may increase such as the lightening of the skin, tissue thinning, or tendon rupture. It is also common to get the largest benefit after the first injection and each additional injection may not last as long or be as helpful. If you do not fully relieve the symptoms with several injections, it may be appropriate to consider other treatments, including surgery. Many surgeons may have a minimum time between injection surgical incision to reduce risk of wound healing problems or infection.
My friend had the injection with ultrasound. Is this necessary?
Some health care providers may choose to use ultrasound to visualize the anatomy for diagnostic reasons or to help determine where to deposit the medication for treatment. This is optional in most cases. Ultrasound technology may incur additional time and cost and is not a technique that is learned and used by all doctors. Most experienced health care providers can provide safe and successful injections without ultrasound.
Steven H. Goldberg is Board Certified in Orthopaedic Surgery and is a fellowship trained hand surgeon with The Subspecialty Certificate in Surgery of the Hand. Dr. Goldberg completed his residency at Rush University Medical Center and his fellowship in Hand and Microvascular Surgery as the Robert E. Carroll Fellow at Columbia Presbyterian Medical Center. He is a member of the ASSH, AAOS, and AMA and currently sees patients at Geisinger Medical Center in Danville and Bloomsburg, Pennsylvania.