A cortisone shot in the shoulder is a common medical intervention designed to reduce pain and inflammation associated with conditions like bursitis, tendonitis, and impingement syndrome. Cortisone, a corticosteroid, is a powerful anti-inflammatory agent that mimics cortisol, a hormone naturally produced by the body. The injection delivers this medication directly to the area of discomfort, often providing significant, though temporary, relief by calming the local immune response. When the expected pain relief does not materialize, it signals that the initial treatment plan may need adjustment.
Reasons Why the Injection May Not Provide Relief
The failure of a cortisone injection to alleviate shoulder pain can often be traced back to issues related to either the injection technique or the underlying medical condition. One possibility is that the medication simply did not reach the intended target, which is typically the inflamed subacromial bursa or joint space. The accuracy of an unguided shoulder injection can vary widely, meaning the corticosteroid may not be concentrated where it is needed most.
The severity or nature of the underlying shoulder problem is another major factor in treatment failure. If the injury involves significant structural damage, such as a large rotator cuff tear or advanced osteoarthritis, reducing inflammation alone may not provide lasting relief. Cortisone is an anti-inflammatory, but it cannot repair torn tissue or replace worn-away cartilage. In these cases, the structural defect is the primary source of pain, and a temporary reduction in surrounding inflammation offers minimal benefit.
Furthermore, the pain source might not be inflammatory at all. Cortisone works only when inflammation is the main driver of symptoms. If the discomfort is primarily due to a mechanical obstruction, nerve irritation, or referred pain from the cervical spine, the anti-inflammatory properties will have little effect. The pain may also be due to a condition like adhesive capsulitis, or frozen shoulder, which involves significant joint capsule thickening and stiffness that an injection cannot resolve.
Re-evaluating the Diagnosis
When a cortisone injection fails to provide relief, the next logical step is a thorough re-evaluation of the initial diagnosis. This process begins with an in-depth physical examination, often performed by a specialist, to reassess the range of motion, muscle strength, and specific points of pain provocation. The physician will perform specialized tests to determine if the location, type, and severity of the pain have changed following the injection.
Advanced imaging studies are often ordered to look for structural issues that may have been missed or underestimated during the initial workup. A magnetic resonance imaging (MRI) scan or a specialized musculoskeletal ultrasound can provide detailed views of soft tissues like tendons, ligaments, and the joint capsule. These tools are useful for identifying the size and location of rotator cuff tears, labral tears, or the extent of cartilage degeneration that may be contributing to the ongoing pain.
A new phase of differential diagnosis is also conducted to consider alternative causes for the shoulder pain. Conditions such as calcific tendonitis or pain referred from the neck, known as cervical radiculopathy, can mimic primary shoulder problems. A failed cortisone shot suggests that the original target was incorrect, prompting the medical team to look closely at other possibilities, including nerve-related issues or autoimmune conditions, which require entirely different treatment pathways.
Non-Surgical Treatment Alternatives
After a failed injection and a comprehensive re-evaluation, the treatment pathway often shifts toward conservative interventions designed to address the root cause of the pain. Physical therapy (PT) is considered the cornerstone of non-surgical management for most shoulder conditions, focusing on improving strength, restoring mobility, and correcting faulty movement patterns. A customized PT program involves gentle exercises to stretch the joint capsule, followed by resistance training to strengthen the rotator cuff and surrounding scapular muscles, which is essential for long-term joint stability and function.
A second cortisone injection may be considered, particularly if the first was unguided and potentially misplaced. However, medical guidelines limit the frequency of these shots due to potential side effects. Repeated injections can compromise tendon healing, weaken local tissues, and may contribute to cartilage damage over time. For pain management, prescription non-steroidal anti-inflammatory drugs (NSAIDs) can be used to control discomfort, but they are generally reserved for short-term use due to potential gastrointestinal side effects.
Alternative injectable therapies have emerged as viable options when cortisone fails. Platelet-Rich Plasma (PRP) therapy involves injecting a concentration of the patient’s own platelets, which contain growth factors, into the injured area to stimulate tissue repair and healing. For conditions like osteoarthritis, injections of hyaluronic acid, a substance that lubricates the joint, can help improve joint function and reduce pain. These regenerative and lubricating injections offer different mechanisms of action compared to cortisone and are utilized to promote tissue health rather than just suppressing inflammation.
When Surgery Becomes Necessary
Surgery is typically reserved as a final option, considered only after conservative, non-surgical treatments have failed to provide relief for a defined period. The decision to proceed with surgery is based on the identification of a structural problem that cannot be fixed through physical therapy or injections.
Indications for surgical intervention include:
- Large, full-thickness tears of the rotator cuff tendons that will not heal on their own.
- Significant shoulder instability caused by recurrent dislocations.
- A severe labral tear that compromises the joint’s integrity.
- A significant bone spur or bony impingement that continually irritates soft tissues.
- Advanced-stage arthritis where joint replacement surgery is the only option to relieve pain and restore function.
Consulting with an orthopedic surgeon is necessary to discuss whether an arthroscopic procedure to repair soft tissues or a joint replacement is the appropriate next step.