If you have joint pain your doctor may recommend having an injection of steroid (also called corticosteroid or cortisone) mixed with local anaesthetic, to relieve the discomfort and reduce inflammation. Steroid injections are given by doctors directly into the affected muscle or joint. They normally take a few days to start working and the effect wears off after several months.
The administering of steroid injections was temporarily halted at the start of the Covid-19 pandemic. This is because the small dosage of injected steroid is known to be a very mild suppressor of the immune system, and doctors were not sure if people who were injected would be more likely to develop more severe symptoms if they caught the coronavirus. However, now that more is known about the virus, and the number of cases in Europe is vastly reduced, you may be able to have corticosteroid injections once more.
The question we are being asked by many patients, alongside when this service will be resumed is ‘is it safe?’
New guidance has recently been issued by the Faculty of Pain Medicine following a survey on the resumption of pain services, published in late May this year. It advises that the steroid injections are now permitted, but the decision to have steroid injections should be based on a balance of risks and benefits. It also states that healthcare organisations should take into account the Covid-19 situation within the individual location as infection rates differ across the country. This means that not all regions are likely to resume offering steroid injections at the same time.
Benefits vs risk
Steroid injections are a very well-established and effective treatment for joint pain. Under normal circumstances, steroid injections carry very small or minor risks of skin or joint infection, skin bleaching and temporary worsening of the pain before improvement. However, new risks posed by the Covid-19 pandemic must now be considered.
If you are in an at-risk group, you are at greater risk from having a steroid injection – your doctor will discuss the specific risks with you. Very high-risk patients should only undergo an injection when there is support from at least two clinicians from the multidisciplinary team. As many shoulder and elbow injections are delivered under ultrasound guidance, this will usually be a consultant surgeon and a consultant radiologist, but if you are regularly treated by a physician they should also be involved. Those at high risk from Covid-19 include people who are immunocompromised or who have a severe lung condition. You can find the full list here: https://www.nhs.uk/conditions/coronavirus-covid-19/people-at-higher-risk/whos-at-higher-risk-from-coronavirus/
Another major concern is the asymptomatic phase of the disease. Most people do not show any symptoms for many days after contracting the virus. Others test positive without displaying symptoms. It is still not conclusively known whether injected steroid around a joint of an asymptomatic carrier of coronavirus could trigger or worsen symptoms of Covid-19. However, a study of 200 patients injected with steroid did not result in more people subsequently testing positive for coronavirus than would be expected.
For the vast majority of the population the risk of a steroid injection is extremely low. However, where they are offered, the minimum effective steroid dose should be used. Your doctor will discuss the benefits versus risk for your individual case so you can make an informed decision.
If you live in England and you or a member of your household are displaying any symptoms of Covid-19, such as fever, cough or loss of sense of taste or smell, you should urgently phone NHS England on 111. They are likely to advise home isolation with your family, and will direct you to the nearest coronavirus test centre. You should not attend any clinic or healthcare facility for a non-urgent condition, such as a painful shoulder or elbow, until you have tested negative or your symptoms have completely resolved.
Alternatives to steroid injections
While steroid injections are acknowledged as an effective way of treating pain and inflammation for many conditions, such as bursitis and arthritis, many other common conditions are equivalently, or sometimes better, treated by a myriad of other non-surgical procedures. Examples include dry needling or PRP injections for tennis/golfer’s elbow, barbotage for calcific tendinitis of the shoulder, hydrodilatation for frozen shoulder, and injections of hyaluronic acid for shoulder and elbow arthritis. More information is available here.
If you have joint or arthritic pain affecting your shoulder, upper arm or elbow, it is important to receive specialist advice so you can understand the options available to you and make a decision based on a full understand of the risks and benefits. Contact Thames Shoulder and Elbow to talk through the options for your particular injury/condition.