Long acting steroid injections are safe and effective if given correctly

BMJ 1995; 310 doi: https://doi.org/10.1136/bmj.310.6987.1139a (Published 29 April 1995) Cite this as: BMJ 1995;310:1139
  1. Malcolm DeSilva
  1. Consultant physician Department of Rheumatology, Prince Charles Hospital, Merthyr Tydfil, Mid Glamorgan CF47 9DT

    EDITOR,—The article on pain in the neck, shoulder, and arm advises on the choice of steroid preparations for intra-articular and soft tissue use in the conditions mentioned.1 I disagree with the authors that the use of long acting depot preparations should be avoided. Several studies have shown that hydrocortisone acetate is the weakest and triamcinolone hexacetonide and triamcinolone acetonide are the most potent of the steroids currently available in terms of both efficacy and duration of action (M deSilva et al, 15th international congress of rheumatology, Paris, 1981).2 3 Furthermore, relatively large volumes of hydrocortisone acetate are needed for a reasonable dose of steroid, and this is particularly relevant in soft tissue injections for medial and lateral humeral epicondylitis, in which injections have to be made into tight restricted spaces. With the more potent preparations, smaller volumes can be used.

    There has been some concern about the use of depot methylprednisolone acetate in soft tissue injections for, for example, the carpal tunnel syndrome. This relates mainly to the fact that this preparation, like hydrocortisone acetate, is a microcrystalline suspension so that crystals may be retained in soft tissues long after the injection. This also explains the postinjection flare seen more commonly with these preparations4 and is extremely rare with triamcinolone hexacetonide. Few of my patients have complained of postinjection pain after the use of this preparation for intra-articular and soft tissue injections, including for golfer's and tennis elbow. The important factor is that these preparations must be used in the proper dosage and not repeated more than once in superficial soft tissue sites. The need to repeat injections is usually due either to poor technique or to wrong diagnosis.

    I also dispute the rationale of injecting steroids and local anaesthetic into the subacromial bursa for disorders of the rotator cuff when direct injection into the shoulder joint is the standard practice. Injection into the subacromial bursa would be more appropriate in acromioclavicular arthritis as direct access to the joint is not particularly easy.


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