Ethics in Medicine

Steroid Injections Not as Safe as Previously Thought

Kristen Sparrow • January 07, 2020

Steroid Injections Not as Safe as Previously Thought


young woman with knee pain
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From Harvard Medical School blog

Calling steroid injections into question

Steroid injections can quickly relieve inflammation in the joints, and the effects may last from several weeks to several months. I’ve seen a number of patients who got significant relief from steroid injections every three or four months. But, a new report of one medical center’s experience and a review of past research came to some concerning conclusions about joint injections for osteoarthritis of the hip or knee. These included:

  • a lack of compelling evidence that they work
  • about 7% to 8% of people getting steroid injections seem to worsen, with their arthritis accelerating “beyond the expected rate”
  • unusual fractures may occur (in about 1% of people)
  • bone damage (called osteonecrosis) (in about 1% of people).

Other side effects include a temporary increase in blood sugar, bleeding into the joint, and, quite rarely, infection. And, of course, the injection itself can be painful, although numbing medication is usually provided.

An increased clinical awareness of adverse joint events after intraarticular corticosteroid injections has led to potential imaging findings and patient characteristics that may assist in identifying which joints could be at risk, although high-quality evidence regarding this topic is lacking.

Osteoarthritis (OA) of the hip and knee is among the most common joint disorders. Intra-articular corticosteroid (IACS) injections are frequently performed to treat OA and other joint-related pain syndromes; however, there is conflicting evidence on their potential benefit. There is a lack of prospective and large retrospective studies evaluating potential joint findings, including increased risk for accelerated OA progression or adverse joint events, after treatment with IACS injection. Four main adverse joint findings have been structurally observed in patients after IACS injections: accelerated OA progression, subchondral insufficiency fracture, complications of osteonecrosis, and rapid joint destruction, including bone loss. Physicians, including radiologists, should be familiar with imaging findings and patient characteristics that may help them identify potential joints at risk for such events. The purpose of this report is to review the existing literature, describe observed adverse joint events after IACS injections, and provide an outlook on how this may affect clinical practice. Additional research endeavors are urgently needed to better understand and identify risk factors prior to intervention and to detect adverse joint events after injection as early as possible to prevent or minimize complications.