Are steroid injections bad for cartilage
One of the most common questions we get asked by patients considering an injection is ‘can steroid injections cause arthritis?’. Arthritis here refers to ‘osteoarthritis’ which is the medical term for ‘wear and tear’ or degenerative changes within the tissues.
The purpose of this blog is to provide relevant information regarding the effects of steroid injections on tissues and joint cartilage.
Key Points:
- Steroid injections are used to minimise the overall systemic dose of steroid to treat inflammation (compared with steroids tablets taken orally)
- By reducing inflammation and also facilitating exercise and rehabilitation, steroid injections can be helpful to joint tissues and may help protect the cartilage
- High doses of steroid injected too frequently into the same joint may have some detrimental effects on the tissues
- Use steroid injections strategically and in conjunction with exercise, rehabilitation and other self-management strategies.
A brief history of steroid injections
The use of steroid injections was originally devised as a way of reducing inflammation within soft tissues and especially in painful swollen joints suffering from arthritis. Their use in medical care has grown massively in the last 50 years as they have been shown to be extremely effective in reducing pain in joints such as knees and shoulders.
The original reason for using steroid injections was to avoid oral steroids (tablets). A steroid injection can target the painful tissue as a single dose procedure. In doing so the total dose of steroid given is significantly reduced and thus will minimise any systemic side effects (side effects around the body) which can be caused by continued use of oral steroids, such as weight gain, increased blood pressure and changes in mood.
What are steroid injections used for?
One of the fundamental aims of a steroid injection is to reduce the inflammation within the joint. It is known that inflammation, as well as causing pain, can be harmful to the soft tissues and the bone. Therefore, reducing inflammation is often a key goal of treatment in the management of arthritic conditions.
One of the main theories and rationale for using cortisone injections was to reduce inflammation and therefore limit the amount of further osteoarthritic changes (damage to the tissues) that occurred within joints as a result of the swelling (Hill, 2007; Ayral, 2005). Progression (worsening) of the radiographic (x-ray) changes found in patients with osteoarthritis has been shown to correlate with increased pain and loss of function (Hill, 2007; Van Spil, 2015). Klocke (2018) found good evidence, when testing patients’ biomarkers, that patients treated with steroid injections had a reduction in degenerative breakdown of their joint cartilage.
Can steroid injections be harmful to our joints?
In recent years it has been proposed that steroid injections may themselves have a detrimental effect on the soft tissues. The precise mechanism for this is unclear. Some studies have hypothesised that there is the potential that steroids could cause an acceleration of the osteoarthritic process.
However, many of these research studies are difficult to draw clear conclusions from. One issue being that patients in these studies who receive treatment of corticosteroid injections typically have more severe levels of pain and osteoarthritic change in the first place. Osteoarthritis is a progressive degenerative disease, so patients’ symptoms and their x-ray findings are normally expected to worsen over time. Another issues is that much of the research looks specifically at osteoarthritis of the knee which is a weightbearing joint and therefore it is not clear if these findings could be extrapolated to other non-weightbearing joints such as shoulder and other upper limb joints.
Findings from studies that have monitored x-ray and MRI findings in patients receiving steroid injections are unclear as to whether any progression in the changes seen relate to steroid injections or the natural progression of osteoarthritis. It is also unclear if the increase in patients’ activity after steroid injection might also lead to further wear and tear. Therefore, when assessing patients’ long term radiographic findings, it is difficult to differentiate between correlation and causation when trying to establish the true relationship between steroids and osteoarthritis.
How can we optimise the treatment effect of steroid injections?
So, on the one hand steroids help by reducing pain and inflammation. By improving mobility and exercise tolerance and reducing inflammation, osteoarthritic (wear and tear) changes may actually be slowed down (Ayral, 2005; Hill, 2007). But on the other hand, the steroids might have a negative impact upon the tissues. Clearly there is a balance to be struck.
Benefits of steroids
Steroid injections can help the joint tissues by:
- Reducing inflammation
- Improving mobility
- Improving one’s ability to perform strengthening exercises by reducing pain.
Managing any possible negative impacts
However, it is proposed that excessive use of steroid injections (high dose injections being given too frequently) may have some detrimental impact on the tissues of the joint.
A systematic review by Wernicke et al. (2015) suggested that the use of low doses of corticosteroid were likely to have a positive impact on tissues including some protection of the cartilage. Whereas the more frequent use of higher dose steroids could potentially lead to an acceleration of cartilage damage.
There have been two recent studies which have specifically attempted to measure the level of arthritic progression in patients receiving steroid injections. Raynauld (2003) found there to be no adverse changes to the cartilage with repeated use of steroid. However, a study by McAlindon et al. (2017) found that patients that had regular high dose steroid injections demonstrated a very small increase in damage to the cartilage after a two year period. There was no evidence to suggest that this had any clinical or functional impact for the patient. Again, a number of other factors have been highlighted, such as patients potentially becoming more active after steroid injections leading to further degenerative change in the joint.
Conclusions
There is evidence that steroid injections have the potential, both directly (via the effects on swelling) and indirectly (by improving mobility), for positive impact on the tissues and cartilage of the joint being injected. Equally it must be recognised that frequent use of high doses of steroid are likely to be detrimental to the tissues and could lead to further arthritis.
It is important therefore to seek professional guidance regarding the safe use of steroid injections and always consider frequency and dose. Typically, the guidance for frequency is to have a maximum of 3-4 injections in any 12 month period into the joint (National Institute for Health and Care Excellence 2017, Neustadt 2006, Genovese 1998, Lane and Thompson 1997). Dose may vary depending upon the specific parameter of the steroid being used and factors such as the size of joint being injected.
If you wish to discuss any of the above information further, please do not hesitate to contact us on injections@complete-physio.co.uk. One of our expert clinicians will be happy to answer any of your questions.
References
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