What are the limitations of steroid injections in the treatment of osteoarthritis (OA)?

Updated: Oct 12, 2020
  • Author: Carlos J Lozada, MD; Chief Editor: Herbert S Diamond, MD  more...
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Some controversial evidence exists regarding frequent steroid injections and subsequent damage to cartilage (chondrodegeneration). Accordingly, it is usually recommended that no more than three injections per year be delivered to any individual osteoarthritic joint. Systemic glucocorticoids have no role in the management of osteoarthritis.

Local anesthetics are often injected along with corticosteroids, to provide immediate pain relief (which also supports the diagnosis of intra-articular pathology), dilute the steroid preparation, and moderate or eliminate the postinjection flare. However, chondrotoxicity (eg, chondrolysis) is a potential drawback. [91, 92]

A review by Kompel et al of intra-articular corticosteroid injections of the hip and knee describes four main adverse events that may occur in injected joints: accelerated osteoarthritis progression; subchondral insufficiency fracture; complications of osteonecrosis; and rapid joint destruction, including bone loss.  These authors recommend that, although high-quality evidence is lacking, certain patient characteristics, including but not limited to acute change in pain not explained by using radiography and no or only mild osteoarthritis at radiography, should lead to careful reconsideration of a planned injection. In such cases, MRI may be diagnostically helpful. [92]

Patients with subchondral insufficiency fracture typically present with acute pain in a weight-bearing joint, despite no identifiable trauma; the pain gradually worsens for weeks. On plain x-rays, the condition may be subtle or occult; magnetic resonance imaging may provide more definitive evidence. Identification of a subchondral insufficiency fracture before intra-articular corticosteroid injection is clinically important, as the steroids may inhibit the healing process. Instead, primary treatment is conservative and includes protected weight-bearing or non–weight-bearing activities. Some authors have proposed adjunctive treatment with bisphosphonates or prostacyclin analogs, but little evidence supports these approaches. [92]

In patients whose x-ray shows no osteoarthritis or only mild osteoarthritis, the authors recommend closely scrutinizing the indication for intra-articular steroid injection, as these patients are at increased risk for developing rapid progressive joint space loss or destructive osteoarthritis. [92]

For more information, see Corticosteroid Injections of Joints and Soft Tissues.

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