The Shoulder

Intra-articular injections

Side Effects

General side effects

There are considerably fewer side effects after intra articular injections of 20 mg triamcinolone than produced after the systemic administration of the same dose.

However, the following side effects are possible:

Hyperglycaemia. Glucocorticoids have an important influence on the intermediary metabolism. They increase circulatory glucose via stimulation of gluconeogenesis and decrease the intracellular use of glucose.
Therefore it is wise to warn diabetic patients for an increase of their blood sugar during the first few days after the local injection of triamcinolone.
Slight suppression of the adrenal cortex after prolonged administration of corticosteroids. Some cortical suppression seems to occur not only when steroids are administered orally but also after intra-articular injections. Prolonged administration renders the adrenals atrophic and provokes suprarenal insufficiency with symptoms such as hypotension, anorexia, fever and generalized joint or muscular pain.
Iatrogenic Cushing's syndrome. The full syndrome with weight gain, depression, insomnia, amenorrhoea, diminished libido, thinned skin, muscular weakness, polyuria and polydypsia is seldom encountered after local use of triamcinolone. Occasionally facial hirsutism and acne may be seen.
Interference with the menstrual cycle. In female patients repeated injections with steroid may lead to dysfunctional uterine bleeding. Steroids may also interfere with hormonal contraceptives. There is no evidence for a teratogenic effect.
Flushing. In the first few days after an intra-articular injection, some patients suffer from erythema and warmth in face, neck and chest. This is a totally benign but rather frequent sensation which is more common after the use of triamcinolone.
Osteoporosis and increased risk of fractures. It is difficult to estimate the exact incidence of osteoporosis provoked by corticosteroids. Nevertheless, special care should be taken when administering them to Postmenopausal females because of the increased likelihood of these side effects.
Allergic and anaphylactic reactions are extremely rare: rash, or bronchospasm and hypotension are the warning signs. Usually the additive carboxymethylcellulose and not the triamcinolone is responsible for the reaction. Sodium carboxymethylcellulose is widely used in the food and pharmaceutical industry as a suspending agent for insoluble powders in aqueous preparations

Local Side Effects

Iatrogenic infectious arthritis. This life-treathening complication is the most feared although it is seldom encountered - iatrogenic infectious arthritis follows one in 14.000-50.000 injections.
Obviously this complication should be avoided by good antiseptic care, especially when the injection is made into a high-risk patient and when infiltrating in the neighbourhood of a joint or in the joint itself.
Flare up of crystal-induced arthritis. During the first 48 hours after an intra-articular injection of a crystalline suspension, a synovitis may flare up as response to the crystals. The mechanism is the same as in gouty arthritis.
Destruction of joint cartilage and evolution of steroid arthropathy. Because steroids depress the synthesis of collagen and proteoglycans, which may result in a loss of stiffness of the cartilage, it has been suggested that intra-articular steroids may hasten the process of arthrosis by a deleterious effect on cartilage.However, the concept of 'corticosteoid arthropathy' is based largely on subprimate animal studies and several anectodical case reports. Limited investigations of primate models have shown no significant long-term deleterious effect on cartilage.
Furthermore, since the shoulder is essentially a non-weight-bearing joint, the chance of provoking a steroid arthropathy is virtually non existent.
However, in the treatment of shoulder lesions with triamcinolone the recommended dose and interval should not be surpassed.
Fat necrosis and skin atrophy. These side effects are due to a faulty injection technique or to leakage of the product after an intra-articular injection.