Rethink Steroid Shots When Your Joint's 'Out of Joint'
Before you rush out to get that corticosteroid injection for your throbbing knee, consider this—a new study says it may do more harm than good.
Your knee joint hurts something fierce. You make a beeline to the nearest doctor’s office for instant relief with a corticosteroid shot. Your knee joint stops hurting. End of story. Right? Not quite. A special report published in Radiology found that corticosteroid injections for the hip and knee could actually be harmful—and that they're not always so well understood.
The injections are anti-inflammatory and are designed to treat osteoarthritis, often just called "arthritis," that causes pain and swelling. The latest research says that adverse events following intra-articular injections—meaning they're delivered right into the joint—can include:
Accelerated osteoarthritis progression
Subchondral insufficiency fracture, a type of stress fracture that occurs below the cartilage on the weight-bearing surface of a bone
Complications of osteonecrosis, a disease caused by reduced blood flow to bones in the joints. In people with healthy bones, new bone replaces old bone. With this condition, bone breaks down faster than he body can make enough new bone—it's death of bone tissue
Rapid joint destruction with bone loss
Some Patients at Higher Risk
Corresponding study author Ali Guermazi, MD, chief of radiology at VA Boston Healthcare System and professor of radiology at Boston University School of Medicine, said in a statement from the Radiology Society of North America (RSNA) that the injections might not only create complications, but also speed up joint destruction and the need for total hip and knee replacements. That flies in the face of previous advice that even if the injections didn't relieve pain, they were otherwise harmless.
His team cautioned that doctors should look more closely at patients referred for injections for pain, and who have mild or nonexistent arthritis on X-rays. Another red flag is when their pain is "disproportionate" to what's seen on those X-rays. Research shows they're at risk of developing rapid progressive joint space loss or destructive arthritis after injections.
In the actual study, the authors detail findings from their city hospital for underserved individuals. They analyzed 459 patients they injected in 2018 in hips and knees: 8% had complications, with 10% in hips and 4% in knees.
The researchers also cautioned about patients who complain of a major change in their pain level when X-rays don't support that, since another underlying condition could be to blame. Candor and disclosure of injection risks should be part of the discussion, especially with younger patients and patients with a recent diagnosis. To that end, Dr. Guermazi said information about risks should be part of the consent discussion when injecting any patient.
In the RSNA statement, he said his team wanted to caution physicians and patients to be careful, because the injections "are likely not as safe as we thought."
What to Do if You Don't Do Injections
Maybe you've thought about injections and you're looking for safe and proven alternative ways to manage your pain. Another reason might be because these injections' efficacy only lasts about a month, says the clinical resource UpToDate which also states that intraarticular hyaluronic acid is "controversial."
Because you need results, the experts at the Mayo Clinic have these helpful suggestions.
What to do: As you go about your day, keep your joints moving, use good posture, and know your limits. This helps you manage your daily activities. You may already know that extra weight puts extra pressure on joints, so if you need to lose some weight, now's a great time to do it. Research has shown that losing only 10% of your weight can reduce pain by half. If you smoke, please stop, as that habit can increase pain.
How to move: Try to stretch, do range-of-motion exercises, gradual progressive strength training, and choose low-impact exercise, like walking, or cycling. As your common sense will tell you, high-impact movement isn't recommended, and neither is repetitive movement.
How to treat: You may have started with over-the-counter medications like acetaminophen or ibuprofen, and maybe you use capsaicin-containing creams. These may work for a while, but if you're relying on pain relief frequently, please talk to your doctor.
About mind and body: Research also shows that depression and arthritis pain can go hand-in-hand. Antidepressants can go far to reduce depression symptoms and arthritis pain.
While on the subject, Mayo recommends you try cognitive behavioral therapy, relaxation therapy like meditation or yoga, and acupuncture, and in a separate category, massage. You can use heating pads—not more than 20 minutes—take hot baths and showers, and even apply warm paraffin wax to joints. If you're using cold applications, they're particularly helpful after a harder exercise session.
Osteoarthritis and corticosteroids study (2019). Intra-articular corticosteroid injections in the hip and knee: perhaps not as safe as we thought? Radiology.