What are the potential side effects of corticosteroid injections for joint and soft tissue injuries?

Updated: Jan 15, 2020
  • Author: Jess D Salinas, Jr, MD; Chief Editor: Elizabeth A Moberg-Wolff, MD  more...
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The packing insert for corticosteroids lists additional significant precautions and contraindications. The physician should be familiar with all of these restrictions before considering injection therapy.

Potential local side effects of corticosteroid injections include infection, subcutaneous atrophy, skin depigmentation, and tendon rupture. [5] These complications often result from poor technique, too large a dose, too frequent a dose, or a failure to mix and dissolve the medications properly.

A study by Kew et al found that in a cohort of patients who underwent arthroscopic shoulder surgery for rotator cuff repair, debridement, or subacromial decompression, the infection rate was significantly greater in those who received an intra-articular corticosteroid injection within 1 month postoperatively than in controls who, following the same surgeries, were not given a steroid injection. However, in patients who received an injection within 2, 3, or 4 months postsurgically, the infection rate did not differ significantly from that of controls. [22]

A study by Baverel et al found that in patients who underwent arthroscopic repair of rotator cuff tears, the retear rate was greatest in those who received postoperative corticosteroid injections (made to the subacromial bursa), while those in whom only a preoperative corticosteroid injection was administered had the lowest retear rate. More specifically, in patients who underwent either postoperative injection or both preoperative and postoperative injection, the retear rates were 19% and 15%, respectively, compared with 6% and 14%, respectively, in patients who received preoperative injection only or no injection. However, the investigators were unable to determine whether postoperative corticosteroid injections truly affected the retear rate or whether outcomes were already poor in the patients who received them. [23]

Unlike the Baverel study, a report by Desai et al did suggest that subacromial corticosteroid injections administered prior to rotator cuff repair can increase the risk for revision surgery, although the association was found only if two or more injections were given within a year preoperatively. Again, however, the investigators could not be certain that the available evidence demonstrated causality between the injections and the need for revision. [24]

Similarly, a literature review by Puzzitiello et al indicated that in patients with rotator cuff tendinosis, corticosteroid injections prior to rotator cuff repair are associated with adverse postsurgical outcomes. The study found that the risk for revision surgery is increased when a single injection is administered up to 1 year preoperatively, while the risk for postoperative infection is increased in association with injection given within a month before repair. According to the investigators, an injection given within 6 months of surgery or 2 or more injections administered within 1 year of surgery carry the greatest adverse outcome risk. [25]

A study by Suh-Burgmann and Liu found a link between corticosteroid injections for joint or back pain and abnormal vaginal bleeding in postmenopausal women. The study found that 17% of postmenopausal women who received a corticosteroid injection reported recent abnormal bleeding, compared with 7% of controls. Among premenopausal women, however, abnormal bleeding rates were similar between those who received a corticosteroid injection and controls (50% vs 43%, respectively). [26]

A retrospective study by Sytsma et al indicated that corticosteroid joint injections can diminish the efficacy of influenza vaccinations. The investigators reported that compared with the total number of vaccinated patients in the study (43,236 persons aged 50 years or older), those who had been vaccinated and had also undergone, directly before or during influenza season, corticosteroid injection to a major joint (4804 patients) had a relative risk of 1.52 for influenza development. In the corticosteroid group, the greatest influenza risk was found in women below age 65 years, prompting the investigators to suggest that these individuals be considered for increased protection through administration of high-dose vaccine. [27]

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