Do Steroid Injections Work for Joint Pain?

By Sarah Golding

Osteoarthritis affects around 600 million people globally. It causes pain, stiffness and reduced joint function – most commonly in the knees, hands and hips.

There’s currently no cure for osteoarthritis. Many people manage the condition through exercise, maintaining a healthy weight, using walking aids and medications.

Commonly used medications include anti-inflammatories and opioids. While these help some, they also carry downsides – including significant side-effects, particularly in over-60s, and risk of addiction from long-term opioid use.

Joint replacement surgery can be very effective for relieving pain and improving mobility, but waiting lists in the last two years hit an all time high, due to increasing demands and reduced capacity since the COVID pandemic.

Surgery also carries risks such as infection, blood clots and nerve damage. Joint replacement surgery is typically suitable for those with advanced stage osteoarthritis.

So how else can osteoarthritis be treated?

Corticosteroid injections, commonly known as steroid injections or cortisone, have been used for joint pain for more than 70 years. They offer a rapid, effective way of reducing pain.

Corticosteroids are anti-inflammatory drugs able to reduce inflammation and pain associated with osteoarthritis. Injecting corticosteroid directly into the joint means it has maximum effect where needed, while minimising effects on the rest of the body.

The effects of steroid injections can last for months, reducing the need for surgery and reliance on prescription drugs. Those most likely to benefit from steroid injections have persistent pain which disrupts sleep and function, and who find other medications unsuitable or ineffective.

Not For Everyone

But as effective as steroid injections can be, their effects will vary from person to person. They may not be as effective in severe cases of osteoarthritis, as they only reduce inflammation and cannot repair damaged or lost cartilage.

Steroid injections may also risk accelerating arthritis or causing bone problems in some people, particularly if used in high doses or too often. Routine use in early stages of osteoarthritis is therefore generally avoided. This is because steroid injections can damage cartilage and bone cells which may further weaken and damage the joint.

Steroid injections may also not be suitable for people already taking high doses of steroids for other health problems (such as rheumatoid arthritis or asthma), and those who have a weakened immune system or are otherwise unwell. Taking too much artificial steroid affects the body’s production of natural steroid, which is essential for our metabolism.

Steroid injections may increase risk of infection following surgery if an injection has been given beforehand. For this reason, the majority of surgeons recommend a minimum of three months between your last injection before surgery.

Although side-effects from steroid injections are fortunately rare, people need to be aware of these to make an informed decision about treatment. These can include: infection, allergic reaction, bleeding, bruising, skin colour changes, temporary flare in pain, bone and joint changes and increased blood sugar levels in those with diabetes.

It’s advised that injections aren’t performed more than every three to four months to reduce risk of side-effects and accelerating the arthritis. With hip injections there is need to be more cautious due to risks of cartilage and bone damage from even just one injection .

Managing Joint Health

Depending on the country, you may be able to have a steroid injection done by your GP, a nurse or a physiotherapist.

Within the UK, first contact physiotherapists working in primary care are accessible in the same way the GP is, many are trained and can offer early access to steroid injections. Injections may be provided within a GP surgery, however hip and spine injections are usually guided by ultrasound or X-ray imaging, which may only be available within a hospital.

Since injections can temporarily reduce osteoarthritis pain, this provides a window of opportunity within which to start exercising. Exercise is important for managing osteoarthritis, as it can strengthen joint-supporting muscles and reduce pain. Physical activity can even be beneficial for those planning to undergo joint replacement surgery as it can improve pain, function and length of hospital stay after surgery.

After injection, it’s recommended people initially rest for a few days, but then gradually increase the amount of exercise they undertake. A physiotherapist can advise on the best types of exercise you can do to help manage your osteoarthritis.

Addressing other contributing factors is essential for managing osteoarthritis, as well. There’s strong evidence linking various metabolic factors to osteoarthritis – such as obesity, diabetes, high cholesterol and high blood pressure. These factors increase inflammation within the body, which affects cartilage in joints. Losing weight where needed is also hugely beneficial in reducing strain on joints.

For those who may not want to use steroid injections, there are other options.

Hyaluronic acid injections, for instance. These help our natural joint lubrication, called synovial fluid. In osteoarthritis, synovial fluid has less viscosity and levels are reduced. Hyaluronic acid is also believed to work as an anti-inflammatory.

Similar to steroid injections, they can reduce pain and increase movement and function. They may be more beneficial to people with earlier stage osteoarthritis and may theoretically have fewer negative effects to cartilage. There may also be value in combining the two types of injection.

Hyaluronic acid has a similar safety profile to corticosteroid, with few reported side-effects. It may, however, take up to 12 weeks for effects to show – though the benefits can last up to six months.

Accessibility is limited in the UK, hyaluronic acid is not currently recommended within NICE guidelines, primarily due to cost effectiveness, so may only be available to those privately funding their care.

Joint injections are not a cure for osteoarthritis. They can have variable effects, and work best combined with other management approaches (such as weight loss and exercise). But with long wait times for surgery, they may offer a valuable way to reduce pain and manage the condition.

Sarah Golding is a Musculoskeletal Physiotherapist and Lecturer at the University of Essex.

This article originally appeared in The Conversation and is republished with permission.   

Researchers Urge Caution on Using Steroid Injections for Pain

By Pat Anson, PNN Editor

Doctors and patients should be more cautious about using corticosteroid injections for pain relief, according to new studies that warn of rare, but serious long-term complications for patients who receive epidurals during childbirth or high doses and multiple injections in their hips.

Researchers at Kaiser Moanalua Medical Center in Hawaii looked at health data for nearly 700 patients with hip osteoarthritis and found that those who received steroid injections were 8.5 times more likely to develop rapidly destructive hip disease (RDHD), a condition that causes the loss of blood flow and death of bone tissue in the hip.

Higher rates of RDHD were especially apparent in patients receiving multiple and/or high-dose injections of the steroid triamcinolone. The risk of RDHD following a single, low-dose injection was about two percent, but rose to five percent following multiple low-dose injections or a single high-dose injection, and up to 10 percent following multiple high-dose injections.

“While the risk of RDHD following a single low-dose (40 mg or less) triamcinolone injection is low, the risk is higher following high-dose (80 mg or more) injection and multiple injections. These findings provide information that can be used to counsel patients about the risks associated with this common procedure. In addition, caution should be taken with intra-articular hip injections utilizing 80 mg of corticosteroid and multiple injections,” wrote lead author Kanu Okike, MD, of Hawaii Permanente Medical Group in Honolulu.

As they became more aware of a possible link with RDHD, orthopedic surgeons at the hospital started ordering fewer hip corticosteroid injections. In subsequent years, the number of RDHD cases decreased. The hospital also added a discussion of post-injection RDHD to the informed consent process for patients and stopped performing high-dose corticosteroid injections.

The study, recently published in The Journal of Bone & Joint Surgery, is believed to be the largest to date of patients with post-injection RDHD.

Epidural Injections

Two new studies have also found that women receiving epidural injections for pain relief during labor are at high risk of long-term headaches and chronic back pain if the needle accidentally punctures the dural lining of the spinal cord. Dural punctures or “wet taps” cause the leak of spinal fluid, which can result in serious neurological complications.  

“I’ve likely performed more than 10,000 epidurals in my lifetime, and I still have wet taps from time to time,” Pamela Flood, MD, a professor of anesthesiology at Stanford University School of Medicine, told Anesthesiology News. “But no matter how many we’ve seen, we still feel terrible about each one. We’re trying to relieve people’s pain and give them a wonderful childbirth experience, and the last thing we want to do is cause them complications.”

A study published in the journal Anaesthesia found that over half of women (58%) with an accidental dural puncture were still experiencing headaches 18 months after the epidural, and nearly half (48%) suffered from chronic low back pain. A recent study in the British Journal of Anaesthesia had similar findings.    

Dural punctures during epidurals are relatively uncommon. Women are usually warned there is a risk of short-term headaches, but not about long-term health problems.

“While this information has been creeping into our consciousness in the form of retrospective trials, only this year has it been confirmed with two large prospective trials,” Flood said. “Unfortunately, clinicians have been slow to hear this, perhaps because we don’t want to admit that the short-term concern that we have been discussing for years carries long-term consequences in a significant percentage of women.”

The two most common types of medications used during epidural injections are anesthetics (lidocaine or bupivacaine) or corticosteroids (betamethasone, dexamethasone, hydrocortisone, methyl-prednisolone, triamcinolone). 

In addition to treating labor pain, epidural steroid injections are widely used for back pain. About 9 million epidural steroid injections are performed annually in the U.S., even though they are not FDA-approved. The FDA has warned that injection of steroids into the epidural space can result in rare but serious neurological problems, including loss of vision, stroke and paralysis. Some patients have also developed arachnoiditis, a chronic and painful inflammation of the spinal cord, after getting steroid injections for back pain.