On the Myth About Steroid Joint Injections

Where does the evidence come from?

When I was fellow, I learned from my mentor Dr. Roy Altman, that joint injections of glucocorticoids (anti-inflammatory steroids) could be administered into a joint about once a month. Now, that's odd, I thought. When I was a resident in internal medicine I was informed by the Orthopedic Attending that one could only inject a given joint about 3 times, ever. Dr. Altman, being one of the world's leading authorities on bone and cartilage, now gave me a different answer and I was not about to argue. So, I decided to research the issue myself.

Every Thursday during lunch hour, the fellows in training met with Dr. Altman in a conference room. We were instructed to discuss various topics of our choosing during this lunch hour. It was the duty of one of the fellows to select a topic and present it to Dr. Altman. Now, Dr. Altman was not exactly the most lenient person in the world. He was known to nit-pick presentations to death. I heard that he made a fellow cry one time. She did graduate eventually and is doing well now in private practice. In any case, I decided to present the topic of steroid injections to the joints- a topic on which Dr. Altman is the foremost authority. What was I thinking?

I started the presentation by stating that (at the time) "there was no long-term evidence that repeated injections to the joints were harmful. Yet, many experts recommended only a few joint injections be administered to a particular joint in a lifetime given the potential damage to the joint. Back in the 1960's, there were a handful of case reports (individual patient reports by doctors) stating that injecting a shoulder joint multiple times, weekly for 10-20 injections for example, would result in damage to the joint*. A severe, destructive arthropathy (joint pathology) and that this treatment should be administered with great caution. Since then, most people only give a few injections to the joints. Animal studies have shown mixed effects on cartilage and are irrelevant in humans. They serve primarily for our understanding of the disease process and, of course, veterinarians." Dr. Altman was nodding. Phew! "The little evidence available at the time," I went on, "suggested that we should not inject the same joint less than 4 weeks apart and probably no more than 4 times a year**." He again was nodding. Interestingly, that was the recommendation that he authored for the American College of Rheumatology guidelines for management of arthritis of the hip and knee.*** I was off the hook!

Several years later, now 2003, a new study was published**** which validated these recommendations. A study comparing steroid injections into the knee with placebo over a two year period found no deleterious effect on the knee joint. Furthermore, the benefit of the injections was found to last anywhere between 4 weeks and 6 months. So now, not only is there no evidence to support the notion that only a limited lifetime number of injections can be given into a joint, but also there is evidence to support the opposing view. Moving forward, the latest edition of Hochberg Textbook of Rheumatology states that "(t)he risk of joint disorganization after steroid injection to the hip and knee may be exaggerated. Experimental joint damage described in rabbits is probably irrelevant and, in a large survey of patients receiving multiple intra-articular steroid injections for osteoarthritis (OA) and rheumatoid arthritis (RA), only two out of 65 patients demonstrated radiologic deterioration, and even this might have been consistent with the natural progression of the disease. It has been argued that, providing the interval between injections is not less than 4 weeks for a weight-bearing joint in man, the benefit is likely to outweigh the damage that might accrue by leaving the inflammatory arthritis untreated. " (p 395)

So, are we going to practice evidenced based medicine? Are we going to apply the best and latest availabe data to our clinical practice? To the naysayers I say, view the evidence. Do not withhold this beneficial treatment from patients simply because you think it may be harmful. The evidence is: benefits far outweight the potential risks. To the fearful patient I say the evidence supports this treatment and is recommended by the American College of Rheumatology. If used judiciously, this is a very helpful adjunct to standard therapy and more than once has helped patients delay or forego surgery. Not to mention relief for those patient who can neither have nor will have surgery.

*Chirurg. 1966 Apr;37(4):178-80.
[Serious complications in intraarticular injections][Article in German]Dederich R.

**Rheumatol Rehabil. 1977 Aug;16(3):137-40.
Repeated corticosteroid injections into knee joints.Balch HW, Gibson JM, El-Ghobarey AF, Bain LS, Lynch MP.The effect of intra-articular injections of corticosteroids repeated over a period extending from four to 15 years on the radiological appearances of knee joints affected by rheumatoid arthritis and osteoarthritis has been studied. In 65 cases, the X-ray films of 15 showed no deterioration, 38 showed minimal or moderate deterioration, 10 showed marked deterioration and only 2 showed gross deterioration. The results do not support the contention that repeated intra-articular injections of corticosteroids will inevitably lead to rapid joint destruction. The authors are of the opinion that intraarticular injections of corticosteroids, if used judiciously, have an important part to play in the management of chronic arthritis.

***Arthritis & Rheumatism
Volume 43, No. 9, September 2000, pp 1905-1915
Special Article
Recommendations for the Medical Management of Osteoarthrits of the Hip and Knee
American College of Rheumatology Subcommittee on Osteoarthritis Guidelines
Members of the Subcommittee on Osteoarthritis Guidelines arc as follows. Roy D. Altman, MD: Department of Veterans Affairs Medical Center, and University of Miami School of Medicine, Miami, Florida; Marc C. Hochberg, MD, MPH: University of Maryland School of Medicine, Baltimore; Roland W. Moskowitz, MD: Case Western Reserve University School of Medicine, Cleveland, Ohio; Thomas J. Schnitzer, MD, PhD: Northwestern University Medical School, Chicago, Illinois.

****Arthritis Rheum. 2003 Nov;48(11):3300. Safety and efficacy of long-term intraarticular steroid injections in osteoarthritis of the knee: a randomized, double-blind, placebo-controlled trial.Raynauld JP, Buckland-Wright C, Ward R, Choquette D, Haraoui B, Martel-Pelletier J, Uthman I, Khy V, Tremblay JL, Bertrand C, Pelletier JP.Hopital Notre-Dame, Centre Hospitalier de l'Universite de Montreal, Montreal, Quebec, Canada. jp.raynauld@videotron.caOBJECTIVE: To evaluate the safety and efficacy of long-term intraarticular (IA) steroid injections for knee pain related to osteoarthritis (OA). METHODS: In a randomized, double-blind trial, 68 patients with OA of the knee received IA injections of triamcinolone acetonide 40 mg (34 patients) or saline (34 patients) into the study knee every 3 months for up to 2 years. The primary outcome variable was radiologic progression of joint space narrowing of the injected knee after 2 years. Measurements of minimum joint space width were performed by an automated computerized method on standardized fluoroscopically guided radiographs taken with the patient standing and with the knee in a semiflexed position. The clinical efficacy measure of primary interest was the pain subscale from the Western Ontario and McMaster Universities OA Index (WOMAC). Efficacy measures of secondary interest were the total score on the WOMAC, physician's global assessment, patient's global assessment, patient's assessment of pain, range of motion (ROM) of the affected knee, and 50-foot walking time. Clinical symptoms were assessed just before each injection. RESULTS: At the 1-year and 2-year followup evaluations, no difference was noted between the two treatment groups with respect to loss of joint space over time. The steroid-injected knees showed a trend toward greater symptom improvement, especially at 1 year, for the WOMAC pain subscale, night pain, and ROM values (P = 0.05) compared with the saline-injected knees. Using area under the curve analyses, knee pain and stiffness were significantly improved throughout the 2-year study by repeated injections of triamcinolone acetonide, but not saline (P <>