The People's Perspective on Medicine

Corticosteroid Injections in Joints Accelerate Arthritis

Doctors frequently use corticosteroid injections into joints to ease pain and stiffness. A new review of the evidence suggests this has serious downsides.
A doctor injects a medical injection of chondroprotector and hyaluronic acid into the knee of a woman to restore the knee joint, cartilage and synovial fluid, close-up

When athletes or older people with osteoarthritis develop joint pain, doctors frequently offer corticosteroid injections into the affected joint. Many clinicians have assumed that this treatment is safe. A new analysis published in the journal Radiology (Oct. 15, 2019) calls that assumption into question.

What Happens To Cartilage After Corticosteroid Injections?

The authors of the latest article on this topic title it:

“Intra-articular Corticosteroid Injections in the Hip and Knee:

“Perhaps Not as Safe as We Thought?”

They report that corticosteroid injections into knees and hips may actually accelerate the progression of osteoarthritis in the long run. The medications that are used can cause joint and cartilage destruction.

Another complication is osteonecrosis or death of bone tissue. People who have received such steroid injections may need total joint replacement sooner than expected.

Corticosteroids and Chondrocyte Toxicity:

How do corticosteroid injections do damage? It all starts with chondrocytes. These are the cells that create healthy cartilage and connective tissue. You want happy chondrocytes because these cells are crucial when it comes to repairing damaged joint tissue and regenerating new cartilage.

Guess what? Corticosteroids are “chondrotoxic.” That is to say, the steroid shots make chondrocytes unhappy. The drugs have a negative impact on cartilage production. Cartilage volume decreases.

When radiologists looked at images of knees that got injected with steroids and compared them to knees injected with saline placebos, the results were not pretty. Corticosteroid injections led to worsening of osteoarthritis (Osteoarthritis and Cartilage, June, 2019).

But wait. It gets worse. Corticosteroid injections are often administered with local anesthetics to reduce discomfort. It turns out that the local anesthetics may also be toxic to chondrocytes (Anesthesia and Analgesia, Aug. 2013). 

But Wait, It Gets Even Worse!

A study published in JAMA (May 16, 2017) compared injections of the steroid triamcinolone to saline on knee cartilage volume and pain in patients with knee osteoarthritis. 

The corticosteroid injections did not ease knee pain better than placebo. Even worse, there was “greater cartilage volume loss.” By now, you know that is not a good thing.

Read more about this intriguing study at this link:

Do Treatments for Knee Arthritis Do More Harm Than Good?

Readers Push Back:

We know that many readers report relief from cortisone injections. They “love” their steroid shots. That’s great, as long those injections are kept to a minimum and are not repeated frequently. We see this treatment as a stopgap measure. Patients should be informed by orthopedic physicians that osteoarthritis may get worse faster and that a joint replacement may become necessary sooner.

Share your own experience with corticosteroid injections below in the comment section. We are eager to hear both sides of the story.

You may find our eGuide to Alternatives for Arthritis of interest. It is an electronic resource.

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    About the Author
    Joe Graedon is a pharmacologist who has dedicated his career to making drug information understandable to consumers. His best-selling book, The People’s Pharmacy, was published in 1976 and led to a syndicated newspaper column, syndicated public radio show and web site. In 2006, Long Island University awarded him an honorary doctorate as “one of the country's leading drug experts for the consumer.” .
    Alternatives for Arthritis
    $5.99

    This eGuide describes nondrug alternatives for arthritis with the latest scientific studies to document anti-inflammatory activity. This comprehensive online guide (too long to print) adds the science behind ancient healing traditions.

    Alternatives for Arthritis
    Citations
    • Kompel AJ et al, "Intra-articular corticosteroid injections in the hip and knee: Perhaps not as safe as we thought?" Radiology, Oct. 15, 2019. https://doi.org/10.1148/radiol.2019190341
    • Zeng C et al, "Intra-articular corticosteroids and the risk of knee osteoarthritis progression: results from the Osteoarthritis Initiative." Osteoarthritis and Cartilage, June, 2019. DOI: 10.1016/j.joca.2019.01.007
    • Breu A et al, "The cytotoxicity of bupivacaine, ropivacaine, and mepivacaine on human chondrocytes and cartilage." Anesthesia and Analgesia, Aug. 2013. DOI: 10.1213/ANE.0b013e31829481ed
    • McAlindon TE et al, "Effect of intra-articular triamcinolone vs saline on knee cartilage volume and pain in patients with knee osteoarthritis: A randomized clinical trial." JAMA, May 16, 2017. doi:10.1001/jama.2017.5283
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    But it gives relief, that is sure, but maybe not to all who takes it. So what do you do?? It is not specified how many shots at what interval and the amount taken when compared with placebo. Other related conditions of patient not disclosed. Will one injection or two in year problematic? Not clear.

    I have been reading comments but saw nothing about steroid injections into the spine. My husband has had several over the years & is scheduled for another one tomorrow. Are they likely to be causing more harm than good? He is in a lot of pain without them, & sometimes they don’t work.

    The review did not address injections into the spine. However, the spine is composed of numerous joints. Very likely the same factors at play in the large joints such as the knee or hip are also relevant in the spine. We will have to wait for research to know for sure, however.

    Many years ago I had bursitis, a painful shoulder condition. I ultimately had surgery but first tried the injections. The first one made me faint, but gave me 6 mos. of relief. The second one only gave me 3 mos. The third helped for about a month, so by then, the writing was on the wall. And that was before non-medical people discovered that these treatments aren’t really so great for one’s health.
    Ice and over-the-counter pain relief are fine for me now until surgery is available.

    At 55 both my knees were getting very painful after working as a licensed massage therapist for nearly 20 years. I was in so much pain at one point I had to have some relief and agreed to “the shots”. I had them in both knees at once, and things went DOWNHILL after that! I should have known better! They never gave me any relief.

    I had my left knee “replaced” at age 57, which was 5 YEARS ago, and went to three different PTs trying to get better, to no avail! The PT mentioned how damaging steroid shots are. My knee only bends to 88 degrees, and the surgeon feels that is “sufficient for daily living”! WRONG, it is nowhere near enabling me to live a normal life without pain! PEOPLE, PLEASE BEWARE!

    I was getting those shots for about two years or so. They only helped a short time, and I think I did get worse much sooner with the shots. I had to have total knee replacement of both knees.

    One shot I completely understand but no more than that. It is proven that repeated injections of steroids will actually break down the joint faster.

    I have had two different yet very, very painful injections into the joint at the base of my thumb, with minimal and not long-lasting pain relief. So I’m very interested in this information. The most pain relief I’ve gotten is from forced rest (in a splint) and controlled exercise/movements.

    2 decades ago, my mother’s orthopedic surgeon said the rheumatologists are good for their business as their patients always find themselves consulting an orthopedic surgeon for joint replacement due to the destruction of cartilage in the injected joint. I, too, have osteoarthritis but for the last 10 years, have opted to treat mine with daily curcumin supplements. Annual xrays show the destruction of cartilage in my joints has been arrested, and I am pain free with full mobility.

    I have arthritis in knee. Dr. Told me if I strengthen the top part of my leg it would help. Well I did not do that. In meantime I got an exercise board to work my midriff. Not aware it would help strengthen the top part of my leg. It did, and now I have no pain. Dr. was right, and no shots.

    Four years ago my knees were so bad I had trouble walking up stairs, and even walking around the block. I had the cortisol shots with temporary relief. Orthopedic surgeon said the only answer was full knee replacement. The joint had advanced osteoarthritis and bone on bone with “no cartilage.”

    I started looking for alternatives and committed to a whole food plant-based diet with limited sugar and oils and regular exercise. Today, at 65 Years old, I am heading out for a fifty mile bike ride. Yesterday I was hiking 5 miles in steep territory, and the day before swam a mile. I wouldn’t believe it if you told me this would be possible 4 years ago.

    I have had injections in my hip for several years now, and finally have relief after I found my current doctor. I sincerely believe the relief comes from a doctor who knows where the correct spot is to inject. She has fixed me up well! I also had started getting shots in my left knee. Well, when she gave me the injection she put the needle in higher up then the other doctor which allowed the solution to slowly be absorbed in a downward movement to take care of all the inflammation.

    I don’t need injections anymore. However, I had a orthopedic doctor inject my elbow, and it did not help but three weeks, and one cannot get another one for six weeks. Also, the other elbow started hurting, and my wrists and hands also hurt now. Not sure if I will continue with him or that procedure, but I am surely having a lot of discomfort, especially in the morning when I wake up. I take Tramadol, which is a life saver!! I also take a prescription anti-inflammatory pill twice a day.

    I have had a cortisone injection in both my knees every 3-4 months for the past four years. I have bone on bone osteoarthritis in both knees. When I would ask my doctor if there was any danger from the shots he would always say no, and that I could continue to get them every three months. My last shot in my left knee was three weeks ago, and I got no relief at all. I am finally going to bite the bullet and have a total knee replacement but I am so afraid that when they cut me open my joints and leg bones will be too eaten away to hold the replacement. Has any body had this many shots?

    I am 30 years old and have already had 8 knee surgeries. I use to do the cortisone shots to get through a season and they worked great, i thought there was nothing negative with getting them and my doctors would give them to me every year.

    Now i have extremely bad arthritis and am waiting to get a total knee replacement once i find a doctor who will do it on someone so young. My recent surgery was a cartilage replacement surgery like Dustin Pedoria had to help regrow my knee cap from all the holes in it, but sadly it’s a temporary solution and i am 2 years post surgery and starting to have problems again.

    So it’s interesting to think those years and years of injections could of actually made my knee problems become worse so quick.

    How long would it take for the shots to do damage? I’m 75 yeare old and have had my first shot for an arthritic knee. My Dr won’t give me more than one every 3 months.
    Another question; I’d like some feedback on the gel injection. Any better than cortisone?
    Thanks

    My sport’s medicine doc warned me that steroid injections would accelerate my osteoarthritis. This was back in 2009 but my orthopedic surgeon said that I had to fail at all medical treatments before he would replace my knees. The lower dose of steroids was fine and worked for 6 months but the higher dose caused my blood pressure to soar, most likely from the increased salt load? So, more than just one hazard.

    I am 72 and have always been very active with gardening, exercise and sports. Several years ago I developed arthritis in both knees. I was managing with some gel injections and occasional cortisone injections. I was playing tennis and going to the gym.

    Last September I had a cortisone injection in both knees, as I was going on a long trip. These were given by a PA in the orthopedic surgeons office. I developed a staph infection in one knee from the injection, but their emergency clinic insisted at first it was synovial fluid, and then gout!

    I spent 5 nights in the hospital and had to have IV antibiotics for 6 weeks. In short, I almost died from this injection. It took me months to recover, and I still have scar tissue in my knee, from the knee arthroscopic irrigation.

    As always the risk of treatment has to be weighed against the benefit. In my opinion if the problem is mainly caused by inflammation ( like rheumatoid arthritis or psoriatic arthritis) the corticosteroid will be more beneficial than when the cause is mainly degenerative ( osteoarthritis).
    For me, three shots of combined corticosteroid and local anesthetic over the course of 6 years kept my iliosacral joints pain free for decades.

    Horses exhibited this side effect of ruined cartilage, from steroid shots in the joints, for years. I saw a race horse with a frozen fetlock at a rescue center that was repeatedly shot up with steroids, with a special plexiglass shoe lift. He could hardly walk.

    Instead of steroids, hunters and jumpers are often given prophylactic shots of Hyaluronic Acid, which is similar to joint fluid and prolongs the joints resiliency with no side effects, assuming the injection is done in a sterile environment.

    I researched further. The Mayo Clinic mentioned Hyaluronic Acid should be used AFTER other treatments didn’t work. I think this is nonsense and should be the FIRST treatment, not the last, so the cartilage can be saved. See article:
    “Hyaluronic Acid (Injection Route)”

    P.S. I can’t help it, just saying, at a noted horse hospital, there’s a machine, related to ultrasound, on wheels, approximately 3 ft. x 3ft x 2.5 ft that gives CRYSTAL clear pictures inside the horse, in real time. The horse I brought in was found to have frayed heart valves, which could be seen clear as day, while the heart was beating. They were able to go to any depth and take digital pictures at any layer. Just think what that would do to the MRI business. Haven’t heard of this for the medical profession yet.

    At around 60 years old I’d have been unable to continue walking my 25-minute walk had I not had a knee injection (without anesthetics). It did not hurt much. A few years later, same thing. Since then — I’m 71 now — I’ve not had any significant problems and have walked every day. I strengthen my knees at home with an easy exercise weekly and eat a very nutritious diet that keeps me thin. Glucosamine/Chondroitin/MSM help, and occasionally, celery seed.

    I had three instances of corticosteroid injection in a hip joint for severe bursitis. It didn’t hurt. It helped. Bursitis cleared up with no relapse in the past thirty years. No arthritis or joint problems in hips again. So far!

    I have arthritis in my left ankle. Using stairs became impossible. And walking was beginning to be so terribly painful. ( I have always been extremely active) My podiatrist gave me my first injection in 2015 , along with a support brace. This gave me back my freedom. So far, I have only had to have 2 other injections, and use my brace only when I have a flare. He has told me that eventually it will get to the point of having to get them more frequently. Right now, they have helped me so much, will do it again when it is needed!

    I received several corticosteriod injections in my affected knee at 6 month intervals. Eventually my knee was bone on bone and I had it replaced. It is the easiest surgery I have undergone. In and out of the hospital after an overnight stay and into physical therapy. I don’t understand why people are resistant to knee replacement surgery. It simply works wonders.

    The introduction to the report states that there it is not set up as a clinical research study, with imaging before and after, etc. It is solely for “education” of radiologists. My experience with joint injection has been for two issues. The first was a knee that was well on the way to replacement and the surgeon explained that. He also told me the limits on the number of injections that he would do (3 in a row) and that a second round likely wouldn’t work. the second was on my hip. The explanation was that hip injections don’t work to relieve pain in the long term, that they were done only once, for diagnostic purposes. If the injection relieved gave significant relief, that indicated need for joint replacement. If not, other reasons for the pain were indicated.
    Do radiologists take the care to discuss such things with patients as a thoughtful surgeon would?

    Thank you. The doctors keep pushing these injections. They also affect healing.

    I had a lot of pain in my knee. I opted for a shot of corticosteroid and had good results but the results lasted for only a few months. The doctor injected a second shot at that second appointment as I was not wanting to go in for surgery. That was one year ago. I am pretty much pain free ,have increased mobility and really don’t think about that knee. I occasionally get a twinge when I pivot but knee pain is 90-95% improved. At 73 yo I will take that result any day. Radiology showed moderate to severe osteoarthritis. I have not returned to see if there are any changes but at my age if I can hold off or prevent surgery, that is what I want to do.

    I have gotten 2 cortisone shots spaced by 6 months in my hip bursa due to bursitis. It has helped tremendously…but both times I came down with shingles a week later! very interesting that the shot lowered my immune system.
    Is this shot in the bursa as dangerous as a knee or hip shot?

    My story is probably nothing compared to others. But I hope some might find it informative. In early 2017, at age 70, I hurt my sciatica trying to move a washing machine by bumping it with my hip. The pain was keeping me awake at night. The doctor gave me corticosteroid shot, administered near the nerve in the Gluteus Maximus. He also prescribed a corticosteroid dose pack, followed by one refill. Those things eliminated the pain alright, but the side and after effects were serious and permanent. Immediately, I suffered weakness, to the degree that my legs were so weak that I had to assist with my arms when sitting down on a toilet. I could not open a bottle of root beer or a jar. That lasted for months.

    Worse, within six months, I developed osteoarthritis in my hands. I was (and still am otherwise) in excellent health. I had above average hand strength. I had recently done carpentry, painting, tiling and electrical work. With the osteoarthritis, I could not open my hands fully. My fingers were swollen, although that has subsided. It compounded the weakness. Now, two and a half years later, some weakness persists. I’d say my current strength is 85% of what it was before. Thankfully, the osteoarthritis does not seem to be worsening. And that’s my story. I would just add this advice: don’t ever, ever, EVER let anyone give you corticosteroids.

    Sure the shots helped and it was heavenly. One worked for almost a year, one six month, one a month. Three did not work.

    I am a senior American and still hurt, but I must get used to the pain because it was the last shot that lasted only a month. Would I do it again if I thought the pain might be stopped? Yes sir e. I think we are intrinsically aware of the negatives, and we still try.

    If I was a young person, I sure would look for another route. I would want to live live as heathfully as I could. We seem to have so few alternatives for extreme pain though.

    Here’s to all the medical improvements being sought in labs throughout our country.

    I guess they must work for some people, but they’ve never helped me AND they are very painful. I’ve found that exercise/movement is much more helpful. X-rays of my knees shows I have very little cartilage in either one. But, exercise has made a huge difference, to the point where I’m able to squat down and get back up with little to no discomfort.

    I’m in my late 60s now, and it seems like I have more joint pain than ever before, but I find that exercise, massage, and heat help a lot. Plus, it’s important to have a healthy diet and maintain a healthy weight, as well.

    I have had 3 injections in my arthritic knee without local anesthetics but over the course of 8 years. My doctor thinks more than one a year could cause damage but not every 3 years. It has given me time to heal a torn meniscus without surgery. I haven’t had an incidence in almost 2 years and the meniscus issue is better and the arthritis is also better.

    I totally agree, steroid injections did more damage than any good. After receiving my first hip injection it helped my pain for about a week. I went through 3 injections, CV each spread out over 9 months. By my 3rd inleejection i was bone on bone.

    What about steroid injections now used for severe stenosis of the spine?

    I had injections in my knee one and half years ago and six months later I had the second series and my knee is doing fine.

    I am so very glad for this information regarding corticosteroid injections. I am on that road leading to shoulder and possibly knee replacement but it is still far off. However, my osteo doctor/surgeon already suggested he could give me a shot of this whenever I want it. Something told me it was not something to be taken lightly. Now I feel certain I would have to get much, much worse before I would allow it. Thank you again.

    I make bone broth and drink it daily using chicken feet and beef bones. Perhaps this would help joints as well as not eating inflammatory foods: gluten, sugar, nightshades, etc

    I recently had 2 cortisone injections at one time, hip and sacroiliac. I was immediately so anxious I was in agony. I am still having trouble sleeping after 3 weeks. My blood pressure shot up to 170 over 85, altho is has gradually normalized. My blood sugar levels were unusually high. I lost 4 pounds in a week, altho I was eating as usual. All in all it was a horrible experience. And only one of the two injections relieved my pain. I will never have another cortisone injection.

    I had a steroid injection in my mid foot (which helped with the pain) but 10 days later began heavy vaginal bleeding. (I’m in my 70’s). Biopsy and ultrasound normal. When I looked up the literature I saw such an association described in a respected medical journal. It was new to the MD but she thought it may well be the explanation.

    Scary stuff! I just had my first cortisone shot for a shoulder issue and had great relief. Having second thoughts about any future shots now.

    Another therapy that only benefits the provider of services, not the patient. Western Medicine is its own worst enemy. All the times I took my neighbor to have these shots (over the last 3 years), not one time did her doc suggest alternative therapies. His comeback was always “It’s bone on bone,” and “You’ll need surgery inevitably.” Her primary physician would not (and still won’t now), allow her to undergo knee surgery. Good for him. Fast forward: she found a great chiropractor here and is doing so much better.

    Just SO GLAD you guys are showing the truth on this subject and everything else you write about. I knew when I discovered your pharmacy back in the day you were not 100% mainstream. Thank you for being SO WONDERFUL AND “The People’s Pharmacy.”

    I had a cortisone injection in my hip 18 months ago and it has been like a miracle; and to date haven’t needed another. I had one in my foot two years ago and it too has worked beautifully. I’m thankful every day for not having pain.

    I have long been aware of the detrimental effects of steroids on the body, and have been concerned about joint injections, which I have had previously .

    I already knew steroid injections into joints accelerates arthritis and erodes joint cartilage since the 1980s; it was in one of my anatomy & physiology books. That’s the side effect of this intervention. I think if it is done once it may be okay, I but I would avoid repeat treatments. I had severe joint pain, but accupuncture did wonders for me including daily exercise such as bike riding.

    I absolutely could not function without my knee injections.

    I’ve gotten repeated injections in my L spine for chronic pain. I have been told I have arthritis in my back and left ankle where I broke it in 4 places years ago, and I get injections for my SI joints. I’m seeking a new place that has a more holistic approach to chronic pain. Had an eval today. I’m so tired of pain but I have always been told that injections are the way to help chronic pain. Have had a major back surgery and it helped greatly but the pain has just relocated. Injections have only masked the pain. Now this says it makes it worse?

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