key: cord-316837-xwc9d5sy
authors: Morgan, Catrin; Dattani, Rupen
title: Should I use steroid injections to treat shoulder pain during the COVID-19 pandemic?
date: 2020-09-09
journal: JSES Int
DOI: 10.1016/j.jseint.2020.07.023
sha: 
doc_id: 316837
cord_uid: xwc9d5sy

Corticosteroid (CS) injections are commonly used both in primary and secondary care in the management of chronic shoulder pain. On March 11 2020, the World Health Organisation (WHO) declared the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2, the causative virus for COVID-19) outbreak a pandemic and global health emergency. There was initial concern with the use of CS injections during the COVID-19 pandemic due to the increased potential for adrenal insufficiency and altered immune response. This led to the publication of guidelines from societies around the world. The aim of this article is to critically appraise the evidence that form the rationale behind these guidelines and to review the alternative treatment options for the management of shoulder pain during the COVID-19 pandemic.

(WHO) declared the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2, the 23 causative virus for COVID-19) outbreak a pandemic and global health emergency 29 . There 24 was initial concern with the use of CS injections during the COVID-19 pandemic due to the 25 increased potential for adrenal insufficiency and altered immune response. This led to the 26 publication of guidelines from societies around the world. 27

The only national guidelines issued in the USA was a joint statement on March 27 th 2020, by 29 the American Society of Regional Anesthesia and Pain Medicine (ASRA) and European 30 Society of Regional Anesthesia and Pain Therapy (ESRA) that advised against elective pain 31 procedures and recommended that clinicians "consider evaluating risks/benefits of steroid 32 injections and use a decreased dose, especially in high-risk patient populations" 1 

The first line of treatment for shoulder pain is usually non-steroidal anti-inflammatory drugs 51 (NSAIDs) and physical therapy. It is however, important to consider the implications of the 52 COVID-19 pandemic on these treatment options. There were initial reports on the possible 53 adverse effects of the use of NSAIDs in acute respiratory tract infections and subsequent 54 concern in relation to COVID-19. Nevertheless, there is currently no evidence that the acute 55 use of NSAIDs causes an increased risk of developing COVID-19 or developing a more 56 severe COVID-19 disease 28 . Current guidance advises patients to continue using NSAIDs for 57 chronic conditions 15 . It is important that patients with musculoskeletal disorders are aware of 58 this information as there is conflicting information in the media which may influence 59 patients' medication adherence. systemic CS was shown to delay viral shedding in some cases and was more likely to cause 106 harm than be of any benefit 19, 21 . It has to be noted that the CS dose used in these studies was 107 significantly higher than that used in for intra-articular or soft tissue injections. 

Acute use of non-steroidal anti-inflammatory drugs (NSAIDs) in people 274 with or at risk of COVID-19 (RPS2001)

The effect of corticosteroids on mortality 276 of patients with influenza pneumonia: a systematic review and meta-analysis

Intra-articular corticosteroids in arthritic disease: a guide to 279 treatment

Martin 285 J Landray, RECOVERY Collaborative Group. Effect of Dexamethasone in Hospitalized 286 Patients with COVID-19: Preliminary

Clinical evidence does not support corticosteroid 289

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COVID-19 associated with acute respiratory distress syndrome

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