Knee Pain Worse After Steroid Injections? Research on Risks

Understanding Why Knee Pain May Worsen After Gel Injections

Knee gel injections, often called steroid or cortisone injections, are a commonly used treatment for knee osteoarthritis pain. However, recent research has raised questions about whether these injections may actually accelerate disease progression and worsen knee damage over time in some patients.

About Knee Osteoarthritis

Osteoarthritis of the knee is a degenerative joint disease where the cartilage that cushions the knee joint gradually wears away. This causes swelling, pain, stiffness and problems moving the knee.

Factors like aging, obesity, joint injury, overuse, and genetics can contribute to developing knee osteoarthritis (KOA). Treatments focus both on managing symptoms and trying to slow progression of cartilage loss.

The Purpose of Gel Injections for Knees

Corticosteroid gel injections have been used for decades to treat KOA flare ups when pain, swelling and inflammation spikes. They provide localized anti-inflammatory effects to help temporarily dampen symptoms.

Injections are minimally invasive with fast pain relief, so they became a routine treatment option for orthopedists and other clinicians managing osteoarthritic knees. It was assumed they posed little downside.

Research Shows Potential for Harm

But recent research has revealed evidence that, while good at immediate symptom relief, repeated steroid knee injections may accelerate loss of cartilage cushioning in the long run.

Two studies published in late 2022, one in JAMA and another in Radiology, made waves by suggesting knee injections potentially worsen osteoarthritis.

JAMA Study Design and Findings

The JAMA study was conducted by researchers at Boston Medical Center and Boston University School of Medicine.

They performed a randomized, placebo-controlled trial with 140 patients who had knee osteoarthritis. The patients received either steroid injections or saltwater placebo injections at the start of the study.

After 78 weeks, the patients who received steroids saw significantly more cartilage loss on MRI scans than the placebo group. They also had reduced joint surface area, indicating progression of arthritic damage.

The researchers concluded repeated steroid injections resulted in significantly greater cartilage loss and no clinical benefit.

Radiology Study Design and Conclusions

The Radiology study was conducted by New York University Grossman School of Medicine researchers using data from the Osteoarthritis Initiative multicenter observational study.

They analyzed MRIs from nearly 1,200 patients with knee osteoarthritis who were followed for four years. About 28% of patients received knee injections during the study period.

Analysis showed patients who received one or more steroid injections had a greater loss of knee cartilage thickness and surface area compared to matched patients who did not receive injections.

The study authors concluded steroid injections "may predispose to greater [cartilage] loss" and advised discussing risks versus benefits with osteoarthritis patients.

Expert Reaction to the New Research Findings

These eye-opening studies made big waves in the osteoarthritis world by suggesting a common, seemingly low risk treatment option may contribute to disease progression.

Cause for Concern

These studies definitely raise concern and caution about the potential disease-modifying effects of repeat steroid injection use, said Dr. Joanne Jordan, Principal Investigator of the Osteoarthritis Initiative analyzed in the Radiology study.

The implications of these studies for clinical care are that the risk/benefit ratio of steroid injections needs updated consideration. We cant make definitive conclusions yet, but should be more judicious using injections, she advised.

Changing Clinical Practice

Dr. David Jevsevar, Chair of the American Academy of Orthopaedic Surgeons Osteoarthritis Clinical Practice Guidelines Expert Panel, believes the new evidence warrants changing typical repeat injection prescribing patterns.

The findings indicate we should limit patients to maybe one or two injections per year rather than a series of three. And we likely shouldnt use injections in younger patients at risk for rapid joint degeneration, he cautioned.

Still Room for Short-Term Use

Steroid injections can provide excellent short-term pain relief when used judiciously. So theres still a role for them in an overall knee osteoarthritis management plan, said Dr. Stephen Messier, co-author of the JAMA study.

But other non-invasive options like weight loss, physical therapy, bracing, topical NSAIDs, should be prioritized over repeat injections for the best long-term outcomes, he advised.

Why Might Steroid Injections Worsen Knee OA?

The biological mechanisms behind the apparent cartilage damage from corticosteroids arent fully clear yet. But experts have theorized reasons repeat injections could negatively impact joint health.

Disrupting Healing Response

Injections may interfere with the bodys attempts to heal joint structures after micro injuries and inflammation flare ups that are part of osteoarthritis.

There is collateral damage with each pain flare up. Steroids may limit the healing factors released in response, explains Dr. Grace Torres, Rheumatologist at Cedars-Sinai Marina Del Rey Hospital.

Weakening Cartilage Integrity

Corticosteroids seem to compromise the strength and elasticity of cartilage over time, making it more prone to wear, tear and faster degeneration with continuous use.

Evidence suggests repeat exposure to steroids impairs the biomechanical properties of knee cartilage, said orthopedic surgeon Dr. Brett Owens.

Masking Symptoms

Steroid injections are so effective at temporarily eliminating pain and inflammation, they may allow patients to overuse unstable knee joints.

Patients feel good enough to exercise vigorously or take up sports again after injections. But structurally compromised cartilage likely worsens faster without pain to hold them back, explains physical therapist Amanda Nixon.

Alternatives to Steroid Injections for Knee Pain

Given the potential downsides, trying options beyond shots first may be wise. Many alternative treatments help alleviate osteoarthritic knee discomfort and swelling without joint-damaging effects.

Weight Loss

Losing excess pounds reduces force and pressure on knee joints with every step. Just 5-10% body weight reduction meaningfully cuts knee osteoarthritis symptoms.

Physical Therapy

Working with a PT strengthens muscles supporting knees, improves flexibility and joint alignment, takes pressure off damaged cartilage, and safely increases physical activity levels able to boost endorphins.

Assistive Devices

Canes, braces, compression sleeves, shoe orthotics and knee taping/strapping stabilizes joints and takes stress off inflamed cartilage to relieve ache.

Topical NSAIDs

Non-steroidal anti-inflammatory creams, gels and patches with ingredients like diclofenac and salicylates reduce localized swelling and knee discomfort when applied to the skin.

Acupuncture

Fine needles strategically placed in the knee region impacts nervous system responses to knee pain signals and stimulates natural healing processes that calm joint inflammation.

Nutritional Support

Glucosamine, chondroitin, Boswellia extracts, omega-3s, turmeric, avocado-soybean unsaponifiables and collagen supplements shown to ease osteoarthritic knee pain and perhaps slow cartilage breakdown.

An integrated plan combining several non-invasive therapies tailored to your needs may offer the most lasting benefits.

Takeaway on Steroid Injections and Knee Osteoarthritis

In summary, concerning new data indicates commonly administered corticosteroid knee injections for osteoarthritis may contribute to faster joint damage and disease progression over time.

Experts now urge more judicious use given potential risks. Priority should be given to safer, conservative treatment approaches whenever possible. More research is still needed, but proactively discussing concerns with your doctor allows making the most informed decisions.

Disclaimer: This article is for informational purposes only and does not constitute medical advice. Always consult with a healthcare professional before starting any new treatment regimen.