Cortisone injections have long been prescribed as a way of treating joint pain and issues that are perhaps stubborn to treatment. Protocols of therapy have often included some short periods of manual therapy and then ‘if that doesn’t work we will give you a cortisone injection’. However, research points to a risk that these injections may not be as complication free as originally thought and may actually be a pre-indicator for early onset arthritis and possible joint complications that require more invasive surgery later.
Corticosteroids are produced by your body in the adrenal glands and are released under stress to minimise inflammation. Corticosteroid injections are a man made injection that has the same effect, effectively downgrading your inflammatory condition which can be particularly useful in conditions such as Bursitis, Carpal Tunnel and tennis/golfers elbow. Treatment regimes limit injections to 2-4 times per year and usually with a 3 month break between injections. The risks of corticosteroid injections have been documented and there are parameters around the amount of injections you should be receiving and strict compliance with time frames and the regularity of injections has always been insisted upon.
At first it was thought that the injections were relatively harmless and that the injections ‘would do no harm’. However research indicates that these shots can actually create issues for people that are more drastic than originally believed. Dr Ali Guermazi, of Boston University School of Medicine published research in 2018 warning that the risk posed by corticosteroid injections can lead to greater complications such as joint collapse and sub-chondral fractures. Dr Guermazi believes that patients should be more informed of these risks before deciding to go ahead with Corticosteroid treatment. He believes that the commonality of these injections is becoming too blaisè without enough consideration for issues that can be attributed to the injections later on. His recommendations are that the Radiographic community needs to invest in further research and that patients should be more aware of the possible complications and risks involved which is currently not the case.
Whilst the instances of complications did only present in a relatively low degree of the research (8%), the complications do present a concern for some amount of persons using the treatment and should be considered in the pre-authorisation of injections. The main areas of concern in 8% of the subjects were:
Flare Reaction - a crystallisation of the injection within the joint space (occurs in approx 2% of cases)
Cartilage softens - the injection creates softness in the articular cartilage which can lead to weakness of the structure that can become permanent. Particularly with people doing regular injections
Hypercortisolism - Cushings Syndrome. An endocrine complication where hormones become unbalanced resulting in obesity, excessive hair growth, menstrual issues in women, weak bones and fertility issues in men.
Osteonecrosis (Avascular Necrosis) - death of bone cells, particularly in the long bones such as the femur or the humerus. Where it occurs close to a joint it can cause a collapse of the joint surface which then leads to arthritic conditions.
Sub Chondral Insufficiency Factor - a stress fracture of the bone directly below the weight bearing surface. Occurs when normal factors are repeatedly applied to compromised bone tissue.
It is worth noting that in much of the explanations of the links between prolonged corticosteroid use and the presenting symptoms of these conditions, that much of the language dismisses the indications of the injections as possible causes. The rates of conditions may be below 10% but that risk is still worth considering. In most of the documented cases there has been some conjecture that patients have ‘repeatedly used corticosteroids and also not downgraded activity sufficiently to alleviate presenting symptoms. That is - they haven’t stopped the action. In these cases, the clients have not stopped the action that is causing them pain. It’s worth noting that whilst low percentages present, it is important to relieve stressors that may be contributing to the onset of these more painful conditions.
The new research from Dr Guermazi, whilst not new is perhaps a check in place to not be complacent in warning people of the risks involved in corticosteroid use as a regular mode of treatment for inflammatory conditions. I’ve stated this before that sometimes we can become too reliant on the magic quick fix needle or injection and not look at our own contributions to conditions and presenting symptoms. Whilst the injections are effective in managing the conditions, they are a short term fix according to research at the Zhejiang University, Hangzhou, China and so relying on these miracle injections to completely manage the issue is perhaps misguided.
Effectively, the injection is a band aid. A short term assist to help downgrade an auto-immune response which can be troublesome and prevent healing. It is always wise though to look beyond the short term pain and be mindful of the full weight of conditions that are presenting and ‘do the work’ to ensure that the joint or bones have the best approach possible to ensure recovery and prevent more debilitating conditions from re-emerging somewhere down the track.
