Intra-articular Ketorolac vs Steroid for Pain: Journal Club

Podcast Summary

This episode of the Pain Exam Podcast, hosted by Dr. David Rosenblum, discusses an interesting article about Ketorolac injections for musculoskeletal conditions. The podcast covers:

• Ketorolac is an NSAID that provides analgesic and anti-inflammatory effects through inhibition of prostaglandin synthesis

• Multiple studies comparing Ketorolac injections to corticosteroids and hyaluronic acid for various conditions

• Research shows Ketorolac injections are equally effective as corticosteroids for subacromial conditions, adhesive capsulitis, carpal-metacarpal joint issues, and hip/knee osteoarthritis

• Ketorolac may be a safer alternative to steroids for certain patients, though it has its own contraindications for those with renal, gastrointestinal, or cardiovascular disease

• Dr. Rosenblum considers the potential of using Ketorolac injections directly at pain sites rather than intramuscularly

Upcoming Courses and Conferences

• Ultrasound courses in New York and Costa Rica (check unwrappedpain.org)

• Private ultrasound sessions available

• Dr. Rosenblum will be speaking at Pain Week about ultrasound in pain practice and PRP

• Presenting at a primary care conference in London

• Teaching ultrasound at ISPN

• LAPS  conference in Chile (Dr. Rosenblum won't attend this year)

• Ketorolac Injections: An Effective Alternative for Musculoskeletal Pain Management

  Musculoskeletal conditions such as bursitis, adhesive capsulitis, and osteoarthritis affect millions and often require injectable therapies to reduce pain and inflammation. Traditionally, corticosteroid injections have been the mainstay treatment. However, concerns over side effects like tendon rupture, cartilage damage, and systemic hyperglycemia have prompted exploration of alternatives. A recent narrative review by Kiel et al. (2024) highlights ketorolac—a parenteral nonsteroidal anti-inflammatory drug (NSAID)—as a promising substitute for corticosteroids in musculoskeletal injections.

  

  Warning: OFF Label use of Ketorolac discussed. Please consult your physician.

  See full article  for details.

  Subacromial Ketorolac Injections for Shoulder Pain

  Subacromial bursitis and impingement syndrome are common causes of shoulder pain and disability. Several randomized controlled trials have shown that subacromial ketorolac injections provide pain relief and functional improvement comparable to corticosteroids:

  • Goyal et al. demonstrated significant reductions in pain scores after subacromial injection of 60 mg ketorolac versus 40 mg methylprednisolone, with no difference in outcomes between groups.
  • Taheri et al. found similar short-term pain relief at 1 and 3 months with either ketorolac or corticosteroid subacromial injections.
  • Kim et al. reported equivalent clinical improvement in rotator cuff syndrome patients receiving ketorolac or triamcinolone injections.
  • Min et al. noted ketorolac led to better forward flexion and patient satisfaction at 4 weeks compared to corticosteroids.

  These studies support ketorolac as an effective agent for subacromial injection, offering an alternative for patients where corticosteroid use is limited.

  Intra-articular Ketorolac Injections for Adhesive Capsulitis and Osteoarthritis

  Adhesive capsulitis (frozen shoulder) and osteoarthritis of the hip, knee, and carpometacarpal joint are often treated with intra-articular corticosteroids. Ketorolac injections have shown comparable efficacy in these conditions:

  • Akhtar et al. found intra-articular ketorolac significantly reduced shoulder pain at 4 weeks in adhesive capsulitis compared to hyaluronic acid.
  • Ahn et al. reported similar pain relief between intra-articular ketorolac and corticosteroid injections in adhesive capsulitis, with ketorolac providing superior should