Pros and Cons of Cortisone Injections

Injections of Intra-articular corticosteroids (IACSs), usually combined with analgesics, are commonly performed to treat pain related to osteoarthritis (OA) e.g., hip and knee OA. While they are common, they are not without their risks. I will go on to talk about these in a moment, however first, it’s important to understand they should only be considered after conservative methods of treatment have failed i.e., oral analgesics, anti-inflammatory agents, exercise or physiotherapy. Intra-articular corticosteroids should be not be first line treatment for OA pain, and if you are recommended for one soon after OA diagnosis or complaints of pain without much other initial intervention, I would encourage you to consider the following pros and cons of IACSs and question the recommendation.

Pros of IACSs

Pain relief: Inflammation and associated pain is a common symptom with progressive OA. Corticosteroids injected into the joint area can reduce the damage caused by synovitis – inflammation from the synovial fluid and membrane that lines the joint – however the corticosteroid can carry its own adverse effects on bone and cartilage. Research has indicated that most people will experience a significant decrease in pain rating scores immediately after the procedure. (1) However, one particular study found that at 14 days post IACSs procedure, pain scores had significantly increased to that of pre IACS pain scores, and only approximately 6% of people reported significant improvements in pain at 6 weeks post procedure (1). Basically, IACS injections may work to relieve inflammation and pain but the benefits are only short term. Furthermore, evidence indicates IACSs may further damage the joint cartilage and even accelerate the development of OA. For example, an extremely robust study conducted in 2017 compared the results of two groups with OA- a group that received IACSs and a placebo group (saline injections)(1). The purpose of this study was to determine the effects of intra-articular injection of 40 mg of triamcinolone acetonide every 3 months on progression of cartilage loss and knee pain(1). The study found knee pain reduced somewhat but there was no significant difference between groups long-term. Furthermore, IACS injections had a greater rate of cartilage loss compared with the placebo group (1). The take home message from this study is that multiple IACS injections over time seem to be significantly detrimental to cartilage and joint health. Anecdotally, I will admit that I have some clients and Infoline callers tell me they had complete and long term pain relief since their IACS injection (though I do wonder of the health of their joint), conversely, others have said they’ve had multiple injections with no desirable outcome (and now I’m concerned!).


Cons of IACSs

The following adverse effects and side effects should be taken into consideration when given the recommendation of a corticosteroid injection.

Some side effects include (depending on type of corticosteroid, dosage and duration):

  • joint pain and swelling
  • stiffness
  • weight gain
  • sleep disturbances
  • gastrointestinal issues
  • osteoporosis
  • pancreatitis

While these side effects are certainly nothing to scoff at, more and more research is indicating that IACSs are causing long term serious and adverse effects of joint health; these adverse effects are highlighted below.

A new paper (2019) has identified some adverse events associated with IACS injections: (3)

  • Accelerated OA progression
  • Subchondral insufficiency fractures (SIF) (factures in the cartilage covering the bone)
  • A risk of osteonecrosis (bone death from lack of blood flow)
  • Rapid joint destruction, including bone loss (meniscal damage, joint space narrowing)

A study recently confirmed and extended these findings with 65 knees showing worsening of radiographic OA in IACS injection group compared to the control group. (4)

Corticosteroid injections may reduce pain and increase function (for the short term) but it does not mean they are good for the joint long term. These adverse events are becoming more recognised by physicians and should be considered carefully before recommending IACS injections. Imaging should be recommended prior to injection (and subsequent injections) to assess the health status of the joint for many reasons (3). For example, identification of a subchondral insufficiency fracture before IACS injection is clinically important, as glucocorticoids (type of corticosteroid) may inhibit healing processes of such a fracture. This is because the IACS injection can reduce pain, which may lead to increased load and weight bearing activities thus increasing the risk of joint collapse by accelerated SIF (3). In other cases where joint collapse is already present, IACS injections may be indicated since total joint replacements may be their only other option to relieve pain and improve function (3).

In conclusion, a one off IACS injection may be necessary and appropriate in certain situations, however, the decision to recommend/go ahead with multiple corticosteroid injections should not be taken lightly; IACS injections may reduce pain associated with OA, but may also come at a price.

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References
  1. McAlindon, T. E., LaValley, M. P., Harvey, W. F., Price, L. L., Driban, J. B., Zhang, M., & Ward, R. J. (2017). Effect of intra-articular triamcinolone vs saline on knee cartilage volume and pain in patients with knee osteoarthritis: a randomized clinical trial. Jama317(19), 1967-1975.
  2. Krych AJ, Griffith TB, Hudgens JL, Kuzma SA, Sierra RJ, Levy BA. Limited therapeutic benefits of intra-articular cortisone injection for patients with femoro-acetabular impingement and labral tear. Knee Surg Sports Traumatol Arthrosc. 2014;22(4):750-755.
  3. Kompel, A. J., Roemer, F. W., Murakami, A. M., Diaz, L. E., Crema, M. D., & Guermazi, A. (2019). Intra-articular corticosteroid injections in the hip and knee: perhaps not as safe as we thought?. Radiology293(3), 656-663.
  4. Zeng, C., Lane, N. E., Hunter, D. J., Wei, J., Choi, H. K., McAlindon, T. E., … & Zhang, Y. (2019). Intra-articular corticosteroids and the risk of knee osteoarthritis progression: results from the Osteoarthritis Initiative. Osteoarthritis and cartilage27(6), 855-862.