title: Variations in corticosteroid/anesthetic injections for painful shoulder conditions: comparisons among orthopaedic surgeons, rheumatologists, and physical medicine and primary-care physicians.
abstract: BACKGROUND
  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.
  
  
  METHODS
  264 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.
  
  
  RESULTS
  169 (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(R) (methylprednisolone acetate) and Kenalog(R) (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.
  
  
  CONCLUSIONS
  Variations 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.
authors.affiliation: Utah Bone and Joint Center, Salt Lake City, Utah, USA. jskedros@utahboneandjoint.com
authors.forename: John G
authors.initials: JG
authors.lastname: Skedros
authors.forename: Kenneth J
authors.initials: KJ
authors.lastname: Hunt
authors.forename: Todd C
authors.initials: TC
authors.lastname: Pitts
mesh_terms: D000305:Adrenal Cortex Hormones / Q000008:administration & dosage*; D000779:Anesthetics, Local / Q000008:administration & dosage*; D001265:Athletic Injuries / Q000188:drug therapy; D012090:Cumulative Trauma Disorders / Q000188:drug therapy; D048909:Diabetes Complications / Q000188:drug therapy; D019983:Guideline Adherence; D006801:Humans; D007061:Idaho; D007270:Injections, Intra-Articular; D008511:Medicine / Q000706:statistics & numerical data*; D009985:Orthopedics / Q000706:statistics & numerical data*; D010810:Physical and Rehabilitation Medicine / Q000706:statistics & numerical data; D010821:Physicians, Family / Q000706:statistics & numerical data; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000639:trends; D012219:Rheumatology / Q000706:statistics & numerical data; D020069:Shoulder Pain / Q000188:drug therapy*; D013038:Specialization; D013178:Sports Medicine / Q000706:statistics & numerical data; D011795:Surveys and Questionnaires; D014589:Utah; D014959:Wyoming
chemical_list: D000305:Adrenal Cortex Hormones; D000779:Anesthetics, Local