Dispelling Myths About Steroid Joint Injections
This is an article published in the Bulletin on the Rheumatic Diseases. It provides a good, consice reivew of the evidence supporting use of steroid injections into the joints. While somewhat technical, it dispells many of the myths that are propagated in the community. Sadly, many physicians are at fault of perpetuating these myths. Evidence Based Medicine supports the use and safety of this form of treatment in various rheumatic syndromes. Enjoy!
Note: unfortunately, the BRD is no longer an active publication. However, you can access some of the previous publications at http://www.arthritis.org/research/bulletin/archives.asp
The Rational Use of Steroid Injections in Arthritis and Nonarticular Musculoskeletal Pain Syndromes
Volume 52, Number 1
Christopher Wise, MD
Division of Rheumatology
Medical College of Virginia
Virginia Commonwealth University Health System
Richmond, VA
Summary Points
Local steroid injections may have lasting benefit when used in one or two involved joints in
rheumatoid arthritis, inflammatory oligoarthritis, peripheral joints in ankylosing spondylitis, juvenile rheumatoid arthritis, and crystal-induced arthritis.
Local steroid injections have short-term benefit in the involved knee of osteoarthritis, painful
shoulder, lateral epicondylitis, and carpal tunnel syndrome.
There is no documented benefit from trigger point injections.
Introduction
The injection of joints and periarticular structures with corticosteroids is commonly used by rheumatologists, orthopedists, and other practitioners to treat musculoskeletal pain. Few procedures in medical practice have the potential to be as effective in achieving symptomatic relief. Surveys have estimated that a majority of internists finishing their residency training feel a need for more training in these procedures.
In 1950, Hollander first reported transient improvement in patients with rheumatoid arthritis injected with cortisone. By the early 1960s, he had reported a series of more than 100,000 injections of joints, bursae, and tendon sheaths in patients (1). Aspiration and therapeutic injection of joints and periarticular tissues has become a common and essential part of rheumatology practice.
The evidence to support the efficacy of injections is mostly anecdotal or based on uncontrolled or retrospective observations.
In general, localized conditions are more amenable to injection than are generalized conditions, and inflammatory types of arthritis are more likely to benefit than noninflammatory or degenerative conditions.
The Clinical Evidence for Efficacy of Steroid Injections
Inflammatory arthritis: Therapeutic injection of corticosteroids is probably most effective in one or two joints affected by inflammatory arthritis. Most of the experience in this area has been reported in rheumatoid arthritis and juvenile rheumatoid arthritis. Anecdotal experience has been reported in crystal-induced arthritis, the spondyloarthropathies, and less common conditions such as systemic lupus and sarcoidosis.
In rheumatoid arthritis, injections are used in individual joints and are adjunctive to disease-modifying drug therapy. Most of Hollander’s early reports suggested long-lasting relief in a vast majority of joints injected, with improvement lasting several months in most patients. In 1972, McCarty reported that injections in the small joints of the hands and wrists resulted in remission in 88% of patients for an average of 22 months, much better than comparable joints not injected in the opposite hands of the same patients (2). In a subsequent report on 956 injections in 140 patients followed for an average of 7 years, 75% of injected joints remained in remission (3). In this series, patients received about 2 injections during the first year of treatment and averaged 0.6 injections per patient-year for the next 15 years.
Corticosteroid injection is considered to be a safe and effective option for prompt relief of acute crystal-induced arthritis, both in gout and pseudogout. In most published series of patients with gout, intraarticular steroids have been successful in relieving pain and swelling completely in over 95% of patients within 48 hours.
Patients with inflammatory oligoarthritis, without definitive diagnosis, can be treated with local steroid injections, and the response to these injections can be used as a prognostic marker. In a series of 51 patients with recent onset inflammatory arthritis involving 5 or fewer joints, injecting all joints with clinical synovitis resulted in improvement in all patients and a complete resolution of synovitis at 2 weeks in 57% of patients. The response at 2 weeks was the best predictor of a continued improvement that persisted for 6 to12 months (4).
Patients with refractory sacroiliac joint pain related to ankylosing spondylitis or other spondyloarthropathies may benefit from injection of the sacroiliac joints. These injections require radiographic confirmation of needle placement in the joint space. In uncontrolled studies, a good response has been reported in roughly 80% of injections, with an average time of improvement of 6 to 9 months, and one study has shown slight benefit of steroid compared to placebo injection.
Joint injection has been utilized with increasing frequency in recent years in juvenile rheumatoid arthritis, particularly in the pauciarticular variant. Complete remission lasting over 6 months has been reported in roughly 65% to 80% of joints injected, most commonly in the knees (5).
Benefit also has been demonstrated in smaller numbers of ankles, wrists, shoulders, elbows, and hips, with a majority of children being able to stop oral medications, and correction of joint contracture noted. One study demonstrated a significant decrease in leg length discrepancy in a population of children treated with repeated injections (average of 3.25 injections per child over 42 months), compared to a population in another center not injected (6).
Osteoarthritis: Clinical studies that support efficacy of steroid injections in osteoarthritis suggest a less predictable and smaller degree of response than in inflammatory arthritis (7). In controlled studies, most benefit compared to placebo seems to last 1 to 6 weeks, with return to the same pain levels seen in placebo groups by around 12 weeks after injection. Factors associated with a better response to steroid injections have included less severe radiographic changes, the presence of effusion at the time of injection, and successful aspiration of fluid at the time of injection.
Injections are not usually performed in patients with osteoarthritis of the hip due to the technical difficulty of accurate needle placement. Reports of response to hip injections, under fluososcopic guidance, suggest a response that lasts for up to 8 to 12 weeks in a majority of patients with milder disease.
Nonarticular conditions: Few controlled studies to support the efficacy of “trigger point injections” have been published. A recent review of 23 papers dealing with trigger-point injections concluded that none of the trials were of sufficient quality to demonstrate or refute the efficacy of any needling technique beyond placebo in the treatment of myofascial pain (8).
Steroid injections are of benefit in the initial management of rotator cuff tendinitis, frozen shoulder, and other causes of shoulder pain. Most controlled studies have demonstrated significant improvement from steroid injection compared to placebo injection, usually lasting up to 4 to 6 months (9).
Local steroid injections also are usually of benefit in the treatment of lateral epicondylitis (tennis elbow). Controlled studies typically document improvement of 90% compared to 50% in placebo treatment in the first month or two after injection, but outcomes at 6 to 12 months are usually not affected (10).
In femoral trochanteric pain syndromes (ie, bursitis), the response rate to locally injected steroids has been reported to be in the 60% to 100% range, with improvement lasting up to 26 weeks in a majority, but no placebo-controlled studies have been done.
Around the knee, anecdotal and retrospective studies have shown that a majority of patients with anserine bursitis, synovial plicas, and other types of periarticular knee pain respond to local steroid injection, but no controlled studies have been done in these conditions.
In carpal tunnel syndrome, most studies report up to 90% short-term relief of symptoms from a single injection, but longer-term relief ranges from 20% to 90%. Surgery is eventually required in about half of patients treated with injection. A good response to local injection is sometimes useful as a diagnostic test and is a predictor of good surgical response.
In prospective studies of patients with de Quervain’s tenosynovitis, 60% to 76% of patients have been adequately controlled with a single injection, and another 10% to 33% required a second injection. About 30% had exacerbations an average of one year later, but only 10% to 17% of patients required surgical release. A small controlled study demonstrated that injection was much better than splinting (11). Similar success rates have been reported in patients with flexor tenosynovitis (trigger fingers) and ganglion cysts.
In general, the response in tarsal tunnel syndrome is usually temporary, while that in Morton’s neuroma is more often prolonged. Reported response rates for plantar fasciitis are variable, but one controlled trial has shown a significant improvement at 1 month compared to placebo but no different from placebo at 3 months (12).
Local injections for neck pain and low back pain have been used for a number of years, but controlled or prospective studies have shown variable results, depending on patient selection and methodology. Most studies of radiographically assisted facet joint injection of steroids in the lumbar or cervical areas show no difference compared to placebo, facet block, or local paraspinous injections. Injections of the sacroiliac joint in patients with non-inflammatory pain have shown a slight benefit from steroids compared to lidocaine alone.
Contraindications to Corticosteroid Injection
Contraindications to diagnostic arthrocentesis and injection are few. Established infection, such as a cellulitis, in the area of the joint is considered to be an absolute contraindication to inserting a needle into a joint. However, if inflammation in an underlying joint or bursa is felt to be the cause of the appearance of infection, then aspiration of the joint or bursa should be attempted.
The risk of introducing blood-borne bacteria into a joint is possible, but such complications are not well-documented. Arthrocentesis through an area of irregular or disrupted skin, as seen in psoriasis, should be avoided due to the increased numbers of colonizing bacteria in these areas.
Caution should be exercised in patients with bleeding disorders or those taking anticoagulants. However, the risk of significant hemarthrosis after arthrocentesis is low, even in patients on regular warfarin therapy with INR levels up to as high as 4.5 (13).
Complications
Iatrogenic infection is the most serious but least common complication of arthrocentesis and joint injection. In Hollander’s earlier large series, an incidence of infection of 0.005% was reported in a series of 400,000 injections (14). Subsequent series have noted a frequency of infection from 1:2,000 to 1:10,000, with higher rates noted in patients with rheumatoid arthritis, occurring almost exclusively in debilitated patients on immunosuppressive therapy.
A recent study suggested that inserting a needle into the joint carries a small fragment of skin into the joint space in most cases, with identifications of bacterial nucleic acide by polymerase chain reaction in about a third of these (15). Considering the rarity of joint infection after arthrocentesis, these findings suggest that bacteria introduced at the time of arthrocentesis are either not viable or quickly cleared in almost all cases.
The most common complications of local steroid injections are related to local irritation of synovial and subcutaneous tissues and atrophy of soft tissues related to the effects of locally injected steroids. Postinjection “flare” may develop in 1% to 6% of patients a few hours after injection and may last up to 48 hours.
Weakening of tendons and tendon rupture also have been reported as a result of locally injected steroids, emphasizing the importance of avoiding direct injection of steroids into the body of tendons. Most reports of tendon rupture have been anecdotal. The risk of tendon rupture is low in the hands and wrists, where tendon rupture has been seen in less than 0.2% in most series. The highest risk for rupture seems to occur in area of the Achilles tendon and plantar fascia, where the risk of rupture after steroid injection has been estimated to be as high as 10% (16).
Systemic absorption invariably occurs with locally injected depot corticosteroids. Studies have documented a decrease in plasma cortisol and suppression of the hypothalamic-pituitary axis lasting from 2 to 7 days after a single injection. In addition, a single injection of triamcinolone in knees of rheumatoid arthritis patients causes a marked reduction in serum markers of bone formation within a day of injection, which returns to normal levels in 14 days, but no change in bone resorption markers, suggesting a potential transient, adverse effect on bone density (17).
Some patients experience prominent erythema, warmth, and diaphoresis of the face and torso within minutes to hours after steroid injections. This is most likely related to systemic absorption, but idiosyncratic reaction to preservatives in steroid preparations also has been implicated. Similarly, some patients may experience other typical metabolic effects of systemic steroids, such as transient rises in blood glucose or decreases in peripheral blood eosinophil or lymphocyte counts.
Avascular necrosis of bone (ischemic necrosis) has long been considered a potential complication of intraarticular steroids, with a reported prevalence of this complication in injected joints ranging from less than 0.1% up to 3%. However, most studies have suggested that the occurrence of this complication is more related to the severity of the associated disease or systemic steroid therapy, rather than to local steroid injection.
The potential for negative effects of locally injected corticosteroids on cartilage metabolism has been controversial. Anecdotal reports of Charcot-like arthropathy attributed to intraarticular steroids first appeared in the late 1950s and 1960s in patients receiving large numbers of injections. Studies in the 1960s and 1970s demonstrated that locally injected steroids caused negative effects in normal animal cartilage, including decreased protein and matrix synthesis, degenerative changes in chondrocytes, and fissures in cartilage matrix. However, similar studies done in primate joints failed to show any negative effects from intraarticular corticosteroids. In addition, studies done in subsequent years have demonstrated protective effects on cartilage lesions and reduction in osteophyte development in animal models of experimentally induced osteoarthritis and some decrease in macrophage infiltration has been demonstrated in humans.
More recent observations in patients with oligoarticular juvenile rheumatoid arthritis suggest that frequent steroid injections have the potential to help protect cartilage from the destructive process of the underlying disease process, and are not associated with negative effects on articular cartilage. In addition, a study of patients with rheumatoid arthritis has shown no increase in the need for subsequent joint replacement surgery in the joints receiving four or more injections in a one-year period of time (18).
General Arthrocentesis Technique and Other Measures
Approaching the joint for aspiration and injection. Sterile technique designed to avoid the introduction of skin bacteria into the joint should be observed in all procedures. Aspiration of fluid prior to steroid injection will increase the degree and duration of efficacy of most of injections. A study of 191 knee injections in patients with rheumatoid arthritis showed that aspiration of fluid reduced the rate of relapse to 23% within a 6-month period compared to 47% in joints not aspirated (19).
Postprocedure instructions and care. Most practitioners advise restricted activities after steroid injections, particularly in weight-bearing joints, but opinions vary and no specific regimen of rest would be considered standard practice. In a large series reported in 1995, McCarty et al used a regimen that emphasized 3 weeks of splinting for upper extremity joints and 6 weeks of crutch walking for lower extremity joints, suggesting that rest after the injection was important in prolonging the effect of injections (3).
One small controlled study showed that rest provided no advantage over regular activities in regard to short- or long-term outcomes. However, in a larger prospective controlled trial of knees in patients with rheumatoid arthritis, a 24-hour period of strict bed rest after injection resulted in a more prolonged improvement that persisted for 6 months compared to patients that were not restricted (20).
Summary
The injection of joints and periarticular structures with corticosteroids continues to be one of the most effective means of short-term treatment of pain. The most benefit has been documented in rheumatoid arthritis and other forms of inflammatory arthritis, but a response is often seen in osteoarthritis for shorter periods of time. Steroid injections are also very effective in the management of painful shoulders, elbows, wrists, and hip girdle areas. Steroid injections for articular syndromes are safe with a relatively low risk of adverse reactions, most of which are self-limited.
References
1. Hollander JL. Intrasynovial corticosteroid therapy: a decade of use. Bull Rheum Dis 1961;11:239-240.
2. McCarty DJ. Treatment of rheumatoid joint inflammation with triamcinolone hexacetonide. Arthritis Rheum 1972;15:157-73.
3. McCarty DJ, Harman JG, Grassanovich JL, Qian C. Treatment of rheumatoid joint inflammation with intrasynovial triamcinolone hexacetonide. J Rheumatol 1995;22:1631-5.
4. Green M, Marzo-Ortega H, Wakefield RJ, et al. Predictors of outcome in patients with oligoarthritis: results of a protocol of intraarticular cortico-steroids to all clinically active joints. Arthritis Rheum 2001;44:1177-83.
5. Padeh S, Passwell JH. Intraarticular corticosteroid injection in the management of children with chronic arthritis. Arthritis Rheum 1998;41:1210-4.
6. Sherry DD, Stein LD, Reed AM, Schanberg LE, Kredich DW. Prevention of leg length discrepancy in young children with pauciarticular juvenile rheumatoid arthritis by treatment with intraarticular steroids. Arthritis Rheum 1999;42:2330-4.
7. Creamer P. Intra-articular corticosteroid treatment in osteoarthritis. Curr Opin Rheumatol 1999;11:417-21.
8. Cummings TM, White AR. Needling therapies in the management of myofascial trigger point pain: a systematic review. Arch Phys Med Rehabil 2001;82:986-92.
9. Green S, Buchbinder R, Glazier R, Forbes A. Systematic review of randomised controlled trials of interventions for painful shoulder: selection criteria, outcome assessment, and efficacy. Bmj 1998;316:354-60.
10. Smidt N, van der Windt DA, Assendelft WJ, Deville WL, Korthals-de Bos IB, Bouter LM. Corticosteroid injections, physiotherapy, or a wait-and-see policy for lateral epicondylitis: a randomised controlled trial. Lancet 2002;359:657-62.
11. Avci S, Yilmaz C, Sayli U. Comparison of nonsurgical treatment measures for de Quervain’s disease of pregnancy and lactation. J Hand Surg [Am] 2002;27:322-4.
12. Crawford F, Atkins D, Young P, Edwards J. Steroid injection for heel pain: evidence of short-term effectiveness. A randomized controlled trial. Rheumatology (Oxford) 1999;38:974-7.
13. Thumboo J, O’Duffy JD. A prospective study of the safety of joint and soft tissue aspirations and injections in patients taking warfarin sodium. Arthritis Rheum 1998;41:736-9.
14. Hollander JL. Intrasynovial corticosteroid therapy in arthritis. Md State Med J 1970;19:62-6.
15. Glaser DL, Schildhorn JC, Bartolozzi AR, et al. Do you really know what is on the tip of your needle? The inadvertant introduction of skin into the joint (abstract). Arthritis Rheum 2000; 43:S149.
16. Acevedo JI, Beskin JL. Complications of plantar fascia rupture associated with corticosteroid injection. Foot Ankle Int 1998;19:91-7.
17. Emkey RD, Lindsay R, Lyssy J, Weisberg JS, Dempster DW, Shen V. The systemic effect of intraarticular administration of corticosteroid on markers of bone formation and bone resorption in patients with rheumatoid arthritis. Arthritis Rheum 1996;39:277-82.
18. Roberts WN, Babcock EA, Breitbach SA, Owen DS, Irby WR. Corticosteroid injection in rheumatoid arthritis does not increase rate of total joint arthroplasty. J Rheumatol 1996;23:1001-4.
19. Weitoft T, Uddenfeldt P. Importance of synovial fluid aspiration when injecting intra-articular corticosteroids. Ann Rheum Dis 2000;59:233-5.
20. Chakravarty K, Pharoah PD, Scott DG. A randomized controlled study of post-injection rest following intra-articular steroid therapy for knee synovitis. Br J Rheumatol 1994;33:464-8.
Note: unfortunately, the BRD is no longer an active publication. However, you can access some of the previous publications at http://www.arthritis.org/research/bulletin/archives.asp
The Rational Use of Steroid Injections in Arthritis and Nonarticular Musculoskeletal Pain Syndromes
Volume 52, Number 1
Christopher Wise, MD
Division of Rheumatology
Medical College of Virginia
Virginia Commonwealth University Health System
Richmond, VA
Summary Points
Local steroid injections may have lasting benefit when used in one or two involved joints in
rheumatoid arthritis, inflammatory oligoarthritis, peripheral joints in ankylosing spondylitis, juvenile rheumatoid arthritis, and crystal-induced arthritis.
Local steroid injections have short-term benefit in the involved knee of osteoarthritis, painful
shoulder, lateral epicondylitis, and carpal tunnel syndrome.
There is no documented benefit from trigger point injections.
Introduction
The injection of joints and periarticular structures with corticosteroids is commonly used by rheumatologists, orthopedists, and other practitioners to treat musculoskeletal pain. Few procedures in medical practice have the potential to be as effective in achieving symptomatic relief. Surveys have estimated that a majority of internists finishing their residency training feel a need for more training in these procedures.
In 1950, Hollander first reported transient improvement in patients with rheumatoid arthritis injected with cortisone. By the early 1960s, he had reported a series of more than 100,000 injections of joints, bursae, and tendon sheaths in patients (1). Aspiration and therapeutic injection of joints and periarticular tissues has become a common and essential part of rheumatology practice.
The evidence to support the efficacy of injections is mostly anecdotal or based on uncontrolled or retrospective observations.
In general, localized conditions are more amenable to injection than are generalized conditions, and inflammatory types of arthritis are more likely to benefit than noninflammatory or degenerative conditions.
The Clinical Evidence for Efficacy of Steroid Injections
Inflammatory arthritis: Therapeutic injection of corticosteroids is probably most effective in one or two joints affected by inflammatory arthritis. Most of the experience in this area has been reported in rheumatoid arthritis and juvenile rheumatoid arthritis. Anecdotal experience has been reported in crystal-induced arthritis, the spondyloarthropathies, and less common conditions such as systemic lupus and sarcoidosis.
In rheumatoid arthritis, injections are used in individual joints and are adjunctive to disease-modifying drug therapy. Most of Hollander’s early reports suggested long-lasting relief in a vast majority of joints injected, with improvement lasting several months in most patients. In 1972, McCarty reported that injections in the small joints of the hands and wrists resulted in remission in 88% of patients for an average of 22 months, much better than comparable joints not injected in the opposite hands of the same patients (2). In a subsequent report on 956 injections in 140 patients followed for an average of 7 years, 75% of injected joints remained in remission (3). In this series, patients received about 2 injections during the first year of treatment and averaged 0.6 injections per patient-year for the next 15 years.
Corticosteroid injection is considered to be a safe and effective option for prompt relief of acute crystal-induced arthritis, both in gout and pseudogout. In most published series of patients with gout, intraarticular steroids have been successful in relieving pain and swelling completely in over 95% of patients within 48 hours.
Patients with inflammatory oligoarthritis, without definitive diagnosis, can be treated with local steroid injections, and the response to these injections can be used as a prognostic marker. In a series of 51 patients with recent onset inflammatory arthritis involving 5 or fewer joints, injecting all joints with clinical synovitis resulted in improvement in all patients and a complete resolution of synovitis at 2 weeks in 57% of patients. The response at 2 weeks was the best predictor of a continued improvement that persisted for 6 to12 months (4).
Patients with refractory sacroiliac joint pain related to ankylosing spondylitis or other spondyloarthropathies may benefit from injection of the sacroiliac joints. These injections require radiographic confirmation of needle placement in the joint space. In uncontrolled studies, a good response has been reported in roughly 80% of injections, with an average time of improvement of 6 to 9 months, and one study has shown slight benefit of steroid compared to placebo injection.
Joint injection has been utilized with increasing frequency in recent years in juvenile rheumatoid arthritis, particularly in the pauciarticular variant. Complete remission lasting over 6 months has been reported in roughly 65% to 80% of joints injected, most commonly in the knees (5).
Benefit also has been demonstrated in smaller numbers of ankles, wrists, shoulders, elbows, and hips, with a majority of children being able to stop oral medications, and correction of joint contracture noted. One study demonstrated a significant decrease in leg length discrepancy in a population of children treated with repeated injections (average of 3.25 injections per child over 42 months), compared to a population in another center not injected (6).
Osteoarthritis: Clinical studies that support efficacy of steroid injections in osteoarthritis suggest a less predictable and smaller degree of response than in inflammatory arthritis (7). In controlled studies, most benefit compared to placebo seems to last 1 to 6 weeks, with return to the same pain levels seen in placebo groups by around 12 weeks after injection. Factors associated with a better response to steroid injections have included less severe radiographic changes, the presence of effusion at the time of injection, and successful aspiration of fluid at the time of injection.
Injections are not usually performed in patients with osteoarthritis of the hip due to the technical difficulty of accurate needle placement. Reports of response to hip injections, under fluososcopic guidance, suggest a response that lasts for up to 8 to 12 weeks in a majority of patients with milder disease.
Nonarticular conditions: Few controlled studies to support the efficacy of “trigger point injections” have been published. A recent review of 23 papers dealing with trigger-point injections concluded that none of the trials were of sufficient quality to demonstrate or refute the efficacy of any needling technique beyond placebo in the treatment of myofascial pain (8).
Steroid injections are of benefit in the initial management of rotator cuff tendinitis, frozen shoulder, and other causes of shoulder pain. Most controlled studies have demonstrated significant improvement from steroid injection compared to placebo injection, usually lasting up to 4 to 6 months (9).
Local steroid injections also are usually of benefit in the treatment of lateral epicondylitis (tennis elbow). Controlled studies typically document improvement of 90% compared to 50% in placebo treatment in the first month or two after injection, but outcomes at 6 to 12 months are usually not affected (10).
In femoral trochanteric pain syndromes (ie, bursitis), the response rate to locally injected steroids has been reported to be in the 60% to 100% range, with improvement lasting up to 26 weeks in a majority, but no placebo-controlled studies have been done.
Around the knee, anecdotal and retrospective studies have shown that a majority of patients with anserine bursitis, synovial plicas, and other types of periarticular knee pain respond to local steroid injection, but no controlled studies have been done in these conditions.
In carpal tunnel syndrome, most studies report up to 90% short-term relief of symptoms from a single injection, but longer-term relief ranges from 20% to 90%. Surgery is eventually required in about half of patients treated with injection. A good response to local injection is sometimes useful as a diagnostic test and is a predictor of good surgical response.
In prospective studies of patients with de Quervain’s tenosynovitis, 60% to 76% of patients have been adequately controlled with a single injection, and another 10% to 33% required a second injection. About 30% had exacerbations an average of one year later, but only 10% to 17% of patients required surgical release. A small controlled study demonstrated that injection was much better than splinting (11). Similar success rates have been reported in patients with flexor tenosynovitis (trigger fingers) and ganglion cysts.
In general, the response in tarsal tunnel syndrome is usually temporary, while that in Morton’s neuroma is more often prolonged. Reported response rates for plantar fasciitis are variable, but one controlled trial has shown a significant improvement at 1 month compared to placebo but no different from placebo at 3 months (12).
Local injections for neck pain and low back pain have been used for a number of years, but controlled or prospective studies have shown variable results, depending on patient selection and methodology. Most studies of radiographically assisted facet joint injection of steroids in the lumbar or cervical areas show no difference compared to placebo, facet block, or local paraspinous injections. Injections of the sacroiliac joint in patients with non-inflammatory pain have shown a slight benefit from steroids compared to lidocaine alone.
Contraindications to Corticosteroid Injection
Contraindications to diagnostic arthrocentesis and injection are few. Established infection, such as a cellulitis, in the area of the joint is considered to be an absolute contraindication to inserting a needle into a joint. However, if inflammation in an underlying joint or bursa is felt to be the cause of the appearance of infection, then aspiration of the joint or bursa should be attempted.
The risk of introducing blood-borne bacteria into a joint is possible, but such complications are not well-documented. Arthrocentesis through an area of irregular or disrupted skin, as seen in psoriasis, should be avoided due to the increased numbers of colonizing bacteria in these areas.
Caution should be exercised in patients with bleeding disorders or those taking anticoagulants. However, the risk of significant hemarthrosis after arthrocentesis is low, even in patients on regular warfarin therapy with INR levels up to as high as 4.5 (13).
Complications
Iatrogenic infection is the most serious but least common complication of arthrocentesis and joint injection. In Hollander’s earlier large series, an incidence of infection of 0.005% was reported in a series of 400,000 injections (14). Subsequent series have noted a frequency of infection from 1:2,000 to 1:10,000, with higher rates noted in patients with rheumatoid arthritis, occurring almost exclusively in debilitated patients on immunosuppressive therapy.
A recent study suggested that inserting a needle into the joint carries a small fragment of skin into the joint space in most cases, with identifications of bacterial nucleic acide by polymerase chain reaction in about a third of these (15). Considering the rarity of joint infection after arthrocentesis, these findings suggest that bacteria introduced at the time of arthrocentesis are either not viable or quickly cleared in almost all cases.
The most common complications of local steroid injections are related to local irritation of synovial and subcutaneous tissues and atrophy of soft tissues related to the effects of locally injected steroids. Postinjection “flare” may develop in 1% to 6% of patients a few hours after injection and may last up to 48 hours.
Weakening of tendons and tendon rupture also have been reported as a result of locally injected steroids, emphasizing the importance of avoiding direct injection of steroids into the body of tendons. Most reports of tendon rupture have been anecdotal. The risk of tendon rupture is low in the hands and wrists, where tendon rupture has been seen in less than 0.2% in most series. The highest risk for rupture seems to occur in area of the Achilles tendon and plantar fascia, where the risk of rupture after steroid injection has been estimated to be as high as 10% (16).
Systemic absorption invariably occurs with locally injected depot corticosteroids. Studies have documented a decrease in plasma cortisol and suppression of the hypothalamic-pituitary axis lasting from 2 to 7 days after a single injection. In addition, a single injection of triamcinolone in knees of rheumatoid arthritis patients causes a marked reduction in serum markers of bone formation within a day of injection, which returns to normal levels in 14 days, but no change in bone resorption markers, suggesting a potential transient, adverse effect on bone density (17).
Some patients experience prominent erythema, warmth, and diaphoresis of the face and torso within minutes to hours after steroid injections. This is most likely related to systemic absorption, but idiosyncratic reaction to preservatives in steroid preparations also has been implicated. Similarly, some patients may experience other typical metabolic effects of systemic steroids, such as transient rises in blood glucose or decreases in peripheral blood eosinophil or lymphocyte counts.
Avascular necrosis of bone (ischemic necrosis) has long been considered a potential complication of intraarticular steroids, with a reported prevalence of this complication in injected joints ranging from less than 0.1% up to 3%. However, most studies have suggested that the occurrence of this complication is more related to the severity of the associated disease or systemic steroid therapy, rather than to local steroid injection.
The potential for negative effects of locally injected corticosteroids on cartilage metabolism has been controversial. Anecdotal reports of Charcot-like arthropathy attributed to intraarticular steroids first appeared in the late 1950s and 1960s in patients receiving large numbers of injections. Studies in the 1960s and 1970s demonstrated that locally injected steroids caused negative effects in normal animal cartilage, including decreased protein and matrix synthesis, degenerative changes in chondrocytes, and fissures in cartilage matrix. However, similar studies done in primate joints failed to show any negative effects from intraarticular corticosteroids. In addition, studies done in subsequent years have demonstrated protective effects on cartilage lesions and reduction in osteophyte development in animal models of experimentally induced osteoarthritis and some decrease in macrophage infiltration has been demonstrated in humans.
More recent observations in patients with oligoarticular juvenile rheumatoid arthritis suggest that frequent steroid injections have the potential to help protect cartilage from the destructive process of the underlying disease process, and are not associated with negative effects on articular cartilage. In addition, a study of patients with rheumatoid arthritis has shown no increase in the need for subsequent joint replacement surgery in the joints receiving four or more injections in a one-year period of time (18).
General Arthrocentesis Technique and Other Measures
Approaching the joint for aspiration and injection. Sterile technique designed to avoid the introduction of skin bacteria into the joint should be observed in all procedures. Aspiration of fluid prior to steroid injection will increase the degree and duration of efficacy of most of injections. A study of 191 knee injections in patients with rheumatoid arthritis showed that aspiration of fluid reduced the rate of relapse to 23% within a 6-month period compared to 47% in joints not aspirated (19).
Postprocedure instructions and care. Most practitioners advise restricted activities after steroid injections, particularly in weight-bearing joints, but opinions vary and no specific regimen of rest would be considered standard practice. In a large series reported in 1995, McCarty et al used a regimen that emphasized 3 weeks of splinting for upper extremity joints and 6 weeks of crutch walking for lower extremity joints, suggesting that rest after the injection was important in prolonging the effect of injections (3).
One small controlled study showed that rest provided no advantage over regular activities in regard to short- or long-term outcomes. However, in a larger prospective controlled trial of knees in patients with rheumatoid arthritis, a 24-hour period of strict bed rest after injection resulted in a more prolonged improvement that persisted for 6 months compared to patients that were not restricted (20).
Summary
The injection of joints and periarticular structures with corticosteroids continues to be one of the most effective means of short-term treatment of pain. The most benefit has been documented in rheumatoid arthritis and other forms of inflammatory arthritis, but a response is often seen in osteoarthritis for shorter periods of time. Steroid injections are also very effective in the management of painful shoulders, elbows, wrists, and hip girdle areas. Steroid injections for articular syndromes are safe with a relatively low risk of adverse reactions, most of which are self-limited.
References
1. Hollander JL. Intrasynovial corticosteroid therapy: a decade of use. Bull Rheum Dis 1961;11:239-240.
2. McCarty DJ. Treatment of rheumatoid joint inflammation with triamcinolone hexacetonide. Arthritis Rheum 1972;15:157-73.
3. McCarty DJ, Harman JG, Grassanovich JL, Qian C. Treatment of rheumatoid joint inflammation with intrasynovial triamcinolone hexacetonide. J Rheumatol 1995;22:1631-5.
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