Injectable Corticosteroids: Take Precautions and Use Caution

Abstract

Corticosteroids are routinely injected into soft tissues, tendon sheaths, bursae, and joints. These anti-inflammatory agents have different potency and solubility, and solubility is inversely correlated with the duration of action. Corticosteroids carry a low risk of complications but commonly cause systemic and local adverse effects. The use of intra-articular corticosteroid injections in the treatment of inflammatory arthritis and osteoarthritis is well established. Evidence also supports the use of injectable corticosteroids in the treatment of inflammatory tenosynovitis and bursitis associated with rheumatic diseases, trigger finger and de Quervain disease, and carpal tunnel syndrome. The role of corticosteroid injections in the management of rotator cuff disease remains unclear. Strong scientific evidence indicates that corticosteroid injections for lateral epicondylosis worsen the long-term outcomes of patients. This review article discusses the considerations related to the use of corticosteroid injections in the management of nonspinal musculoskeletal conditions.

Keywords

corticosteroid - intra-articular injection - soft tissue injection - tendinopathy - musculoskeletal disorders

• References

• 1 Burns CM. The history of cortisone discovery and development. Rheum Dis Clin North Am 2016; 42 (1) 1-14 , vii
• 2 Hollander JL, Brown Jr EM, Jessar RA, Brown CY. Hydrocortisone and cortisone injected into arthritic joints; comparative effects of and use of hydrocortisone as a local antiarthritic agent. J Am Med Assoc 1951; 147 (17) 1629-1635
• 3 MacMahon PJ, Eustace SJ, Kavanagh EC. Injectable corticosteroid and local anesthetic preparations: a review for radiologists. Radiology 2009; 252 (3) 647-661
• 4 Deshmukh AJ, Thakur RR, Goyal A, Klein DA, Ranawat AS, Rodriguez JA. Accuracy of diagnostic injection in differentiating source of atypical hip pain. J Arthroplasty 2010; 25 (6, Suppl): 129-133
• 5 Dragoo JL, Korotkova T, Kanwar R, Wood B. The effect of local anesthetics administered via pain pump on chondrocyte viability. Am J Sports Med 2008; 36 (8) 1484-1488
• 6 Marsland D, Mumith A, Barlow IW. Systematic review: the safety of intra-articular corticosteroid injection prior to total knee arthroplasty. Knee 2014; 21 (1) 6-11
• 7 Ostergaard M, Halberg P. Intra-articular corticosteroids in arthritic disease: a guide to treatment. BioDrugs 1998; 9 (2) 95-103
• 8 Raynauld JP, Buckland-Wright C, Ward R , et al. Safety and efficacy of long-term intraarticular steroid injections in osteoarthritis of the knee: a randomized, double-blind, placebo-controlled trial. Arthritis Rheum 2003; 48 (2) 370-377
• 9 Coombes BK, Bisset L, Brooks P, Khan A, Vicenzino B. Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: a randomized controlled trial. JAMA 2013; 309 (5) 461-469
• 10 Coombes BK, Bisset L, Vicenzino B. Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials. Lancet 2010; 376 (9754): 1751-1767
• 11 Scott A, Khan KM. Corticosteroids: short-term gain for long-term pain?. Lancet 2010; 376 (9754): 1714-1715
• 12 Ramamoorthy S, Cidlowski JA. Corticosteroids: mechanisms of action in health and disease. Rheum Dis Clin North Am 2016; 42 (1) 15-31 , vii
• 13 Barnes PJ. Anti-inflammatory actions of glucocorticoids: molecular mechanisms. Clin Sci (Lond) 1998; 94 (6) 557-572
• 14 Cole BJ, Schumacher Jr HR. Injectable corticosteroids in modern practice. J Am Acad Orthop Surg 2005; 13 (1) 37-46
• 15 Derby R, Lee SH, Date ES, Lee JH, Lee CH. Size and aggregation of corticosteroids used for epidural injections. Pain Med 2008; 9 (2) 227-234
• 16 Benzon HT, Chew TL, McCarthy RJ, Benzon HA, Walega DR. Comparison of the particle sizes of different steroids and the effect of dilution: a review of the relative neurotoxicities of the steroids. Anesthesiology 2007; 106 (2) 331-338
• 17 Tiso RL, Cutler T, Catania JA, Whalen K. Adverse central nervous system sequelae after selective transforaminal block: the role of corticosteroids. Spine J 2004; 4 (4) 468-474
• 18 Benzon HT, Gissen AJ, Strichartz GR, Avram MJ, Covino BG. The effect of polyethylene glycol on mammalian nerve impulses. Anesth Analg 1987; 66 (6) 553-559
• 19 Shah K, Watson D, Campbell C, Meek RMD. Intra-articular injection composed of steroid, iohexol and local anaesthetic: is it stable?. Br J Radiol 2009; 82 (974) 109-111
• 20 Brinks A, Koes BW, Volkers AC, Verhaar JA, Bierma-Zeinstra SM. Adverse effects of extra-articular corticosteroid injections: a systematic review. BMC Musculoskelet Disord 2010; 11: 206
• 21 Gray RG, Tenenbaum J, Gottlieb NL. Local corticosteroid injection treatment in rheumatic disorders. Semin Arthritis Rheum 1981; 10 (4) 231-254
• 22 McGarry JG, Daruwalla ZJ. The efficacy, accuracy and complications of corticosteroid injections of the knee joint. Knee Surg Sports Traumatol Arthrosc 2011; 19 (10) 1649-1654
• 23 Weston VC, Jones AC, Bradbury N, Fawthrop F, Doherty M. Clinical features and outcome of septic arthritis in a single UK Health District 1982–1991. Ann Rheum Dis 1999; 58 (4) 214-219
• 24 Youssef J, Novosad SA, Winthrop KL. Infection risk and safety of corticosteroid use. Rheum Dis Clin North Am 2016; 42 (1) 157-176 , ix–x
• 25 Ostensson A, Geborek P. Septic arthritis as a non-surgical complication in rheumatoid arthritis: relation to disease severity and therapy. Br J Rheumatol 1991; 30 (1) 35-38
• 26 Papavasiliou AV, Isaac DL, Marimuthu R, Skyrme A, Armitage A. Infection in knee replacements after previous injection of intra-articular steroid. J Bone Joint Surg Br 2006; 88 (3) 321-323
• 27 Karuppiah SV, Gibson P. The safety of hip injection with corticosteroid in the diagnosis and treatment of osteoarthritis. Hip Int 2007; 17 (1) 36-39
• 28 Sankar B, Seneviratne S, Radha S, Rajeev A, Banaszkiewicz P. Safety of total hip replacement following an intra-articular steroid hip injection—an audit. Acta Orthop Belg 2012; 78 (2) 183-186
• 29 McIntosh AL, Hanssen AD, Wenger DE, Osmon DR. Recent intraarticular steroid injection may increase infection rates in primary THA. Clin Orthop Relat Res 2006; 451 (451) 50-54
• 30 Berger RG, Yount WJ. Immediate “steroid flare” from intraarticular triamcinolone hexacetonide injection: case report and review of the literature. Arthritis Rheum 1990; 33 (8) 1284-1286
• 31 Young P, Homlar KC. Extreme postinjection flare in response to intra-articular triamcinolone acetonide (Kenalog). Am J Orthop 2016; 45 (3) E108-E111
• 32 Duclos M, Guinot M, Colsy M , et al. High risk of adrenal insufficiency after a single articular steroid injection in athletes. Med Sci Sports Exerc 2007; 39 (7) 1036-1043
• 33 Everett CR, Baskin MN, Speech D, Novoseletsky D, Patel R. Flushing as a side effect following lumbar transforaminal epidural steroid injection. Pain Physician 2004; 7 (4) 427-429
• 34 Habib GS, Bashir M, Jabbour A. Increased blood glucose levels following intra-articular injection of methylprednisolone acetate in patients with controlled diabetes and symptomatic osteoarthritis of the knee. Ann Rheum Dis 2008; 67 (12) 1790-1791
• 35 Mens JM, Nico de Wolf A, Berkhout BJ, Stam HJ. Disturbance of the menstrual pattern after local injection with triamcinolone acetonide. Ann Rheum Dis 1998; 57 (11) 700
• 36 Gilsanz V, Bernstein BH. Joint calcification following intra-articular corticosteroid therapy. Radiology 1984; 151 (3) 647-649
• 37 Derendorf H, Möllmann H, Grüner A, Haack D, Gyselby G. Pharmacokinetics and pharmacodynamics of glucocorticoid suspensions after intra-articular administration. Clin Pharmacol Ther 1986; 39 (3) 313-317
• 38 Céleste C, Ionescu M, Robin Poole A, Laverty S. Repeated intraarticular injections of triamcinolone acetonide alter cartilage matrix metabolism measured by biomarkers in synovial fluid. J Orthop Res 2005; 23 (3) 602-610
• 39 Todhunter RJ, Fubini SL, Wootton JA, Lust G. Effect of methylprednisolone acetate on proteoglycan and collagen metabolism of articular cartilage explants. J Rheumatol 1996; 23 (7) 1207-1213
• 40 Fubini SL, Todhunter RJ, Burton-Wurster N, Vernier-Singer M, MacLeod JN. Corticosteroids alter the differentiated phenotype of articular chondrocytes. J Orthop Res 2001; 19 (4) 688-695
• 41 Pelletier JP, Mineau F, Raynauld JP, Woessner Jr JF, Gunja-Smith Z, Martel-Pelletier J. Intraarticular injections with methylprednisolone acetate reduce osteoarthritic lesions in parallel with chondrocyte stromelysin synthesis in experimental osteoarthritis. Arthritis Rheum 1994; 37 (3) 414-423
• 42 Vandeweerd JM, Zhao Y, Nisolle JF , et al. Effect of corticosteroids on articular cartilage: have animal studies said everything?. Fundam Clin Pharmacol 2015; 29 (5) 427-438
• 43 Balch HW, Gibson JM, El-Ghobarey AF, Bain LS, Lynch MP. Repeated corticosteroid injections into knee joints. Rheumatol Rehabil 1977; 16 (3) 137-140
• 44 Driban J, Lavalley MP, Price LL, Harvey WF, McAlindon TE. Intra-articular corticosteroids are safe and have no major effect on structural progression of synovitic knee OA: a 2-year randomized controlled trial of 3-monthly triamcinolone hexacetonide [abstract]. Arthritis Rheum 2015;67(Suppl. 10). Available at: http://acrabstracts.org/abstract/intra-articular-corticosteroids-are-safe-and-have-no-major-effect-on-structural-progression-of-synovitic-knee-oa-a-2-year-randomized-controlled-trial-of-3-monthly-triamcinolone-hexacetonide/ . Accessed December 20, 2016
• 45 Nichols AW. Complications associated with the use of corticosteroids in the treatment of athletic injuries. Clin J Sport Med 2005; 15 (5) 370-375
• 46 Wong MW, Tang YN, Fu SC, Lee KM, Chan KM. Triamcinolone suppresses human tenocyte cellular activity and collagen synthesis. Clin Orthop Relat Res 2004; (421) 277-281
• 47 Wong MW, Tang YY, Lee SK, Fu BS, Chan BP, Chan CK. Effect of dexamethasone on cultured human tenocytes and its reversibility by platelet-derived growth factor. J Bone Joint Surg Am 2003; 85-A (10) 1914-1920
• 48 Wong MW, Lui WT, Fu SC, Lee KM. The effect of glucocorticoids on tendon cell viability in human tendon explants. Acta Orthop 2009; 80 (3) 363-367
• 49 Dean BJ, Lostis E, Oakley T, Rombach I, Morrey ME, Carr AJ. The risks and benefits of glucocorticoid treatment for tendinopathy: a systematic review of the effects of local glucocorticoid on tendon. Semin Arthritis Rheum 2014; 43 (4) 570-576
• 50 Chen SK, Lu CC, Chou PH, Guo LY, Wu WL. Patellar tendon ruptures in weight lifters after local steroid injections. Arch Orthop Trauma Surg 2009; 129 (3) 369-372
• 51 Björkman A, Jörgsholm P. Rupture of the extensor pollicis longus tendon: a study of aetiological factors. Scand J Plast Reconstr Surg Hand Surg 2004; 38 (1) 32-35
• 52 Kondo T, Kitazawa R, Yamaguchi A, Kitazawa S. Dexamethasone promotes osteoclastogenesis by inhibiting osteoprotegerin through multiple levels. J Cell Biochem 2008; 103 (1) 335-345
• 53 Foremny GB, Pretell-Mazzini J, Jose J, Subhawong TK. Risk of bleeding associated with interventional musculoskeletal radiology procedures. A comprehensive review of the literature. Skeletal Radiol 2015; 44 (5) 619-627
• 54 Cheng OT, Souzdalnitski D, Vrooman B, Cheng J. Evidence-based knee injections for the management of arthritis. Pain Med 2012; 13 (6) 740-753
• 55 Eder L, Chandran V, Ueng J , et al. Predictors of response to intra-articular steroid injection in psoriatic arthritis. Rheumatology (Oxford) 2010; 49 (7) 1367-1373
• 56 Uthman I, Raynauld JP, Haraoui B. Intra-articular therapy in osteoarthritis. Postgrad Med J 2003; 79 (934) 449-453
• 57 Atchia I, Kane D, Reed MR, Isaacs JD, Birrell F. Efficacy of a single ultrasound-guided injection for the treatment of hip osteoarthritis. Ann Rheum Dis 2011; 70 (1) 110-116
• 58 Zhang W, Doherty M, Arden N , et al; EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT). EULAR evidence based recommendations for the management of hip osteoarthritis: report of a task force of the EULAR Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT). Ann Rheum Dis 2005; 64 (5) 669-681
• 59 Zhang W, Nuki G, Moskowitz RW , et al. OARSI recommendations for the management of hip and knee osteoarthritis: part III: Changes in evidence following systematic cumulative update of research published through January 2009. Osteoarthritis Cartilage 2010; 18 (4) 476-499
• 60 Leirisalo-Repo M. What is the best treatment strategy for early RA?. Best Pract Res Clin Rheumatol 2013; 27 (4) 523-536
• 61 Kruse DW. Intraarticular cortisone injection for osteoarthritis of the hip. Is it effective? Is it safe?. Curr Rev Musculoskelet Med 2008; 1 (03/04) 227-233
• 62 Lomonte AB, de Morais MG, de Carvalho LO, Zerbini CA. Efficacy of Triamcinolone hexacetonide versus methylprednisolone acetate intraarticular injections in knee osteoarthritis: a randomized, double-blinded, 24-week study. J Rheumatol 2015; 42 (9) 1677-1684
• 63 Althoff CE, Bollow M, Feist E , et al. CT-guided corticosteroid injection of the sacroiliac joints: quality assurance and standardized prospective evaluation of long-term effectiveness over six months. Clin Rheumatol 2015; 34 (6) 1079-1084
• 64 Arden NK, Reading IC, Jordan KM , et al. A randomised controlled trial of tidal irrigation vs corticosteroid injection in knee osteoarthritis: the KIVIS Study. Osteoarthritis Cartilage 2008; 16 (6) 733-739
• 65 Hirsch G, Kitas G, Klocke R. Intra-articular corticosteroid injection in osteoarthritis of the knee and hip: factors predicting pain relief—a systematic review. Semin Arthritis Rheum 2013; 42 (5) 451-473
• 66 Garg N, Perry L, Deodhar A. Intra-articular and soft tissue injections, a systematic review of relative efficacy of various corticosteroids. Clin Rheumatol 2014; 33 (12) 1695-1706
• 67 Meenagh GK, Patton J, Kynes C, Wright GD. A randomised controlled trial of intra-articular corticosteroid injection of the carpometacarpal joint of the thumb in osteoarthritis. Ann Rheum Dis 2004; 63 (10) 1260-1263
• 68 Spolidoro Paschoal NdeO, Natour J, Machado FS, de Oliveira HA, Furtado RN. Effectiveness of triamcinolone hexacetonide intraarticular injection in interphalangeal joints: a 12-week randomized controlled trial in patients with hand osteoarthritis. J Rheumatol 2015; 42 (10) 1869-1877
• 69 Speed CA. Fortnightly review: corticosteroid injections in tendon lesions. BMJ 2001; 323 (7309): 382-386
• 70 Gutierrez M, Di Matteo A, Rosemffet M , et al; Pan-American League against Rheumatisms (PANLAR) Ultrasound Study Group. Short-term efficacy to conventional blind injection versus ultrasound-guided injection of local corticosteroids in tenosynovitis in patients with inflammatory chronic arthritis: A randomized comparative study. Joint Bone Spine 2016; 83 (2) 161-166
• 71 Järvinen M, Józsa L, Kannus P, Järvinen TL, Kvist M, Leadbetter W. Histopathological findings in chronic tendon disorders. Scand J Med Sci Sports 1997; 7 (2) 86-95
• 72 Peters-Veluthamaningal C, Winters JC, Groenier KH, Jong BM. Corticosteroid injections effective for trigger finger in adults in general practice: a double-blinded randomised placebo controlled trial. Ann Rheum Dis 2008; 67 (9) 1262-1266
• 73 Peters-Veluthamaningal C, Winters JC, Groenier KH, Meyboom-DeJong B. Randomised controlled trial of local corticosteroid injections for de Quervain's tenosynovitis in general practice. BMC Musculoskelet Disord 2009; 10: 131
• 74 Castellanos J, Muñoz-Mahamud E, Domínguez E, Del Amo P, Izquierdo O, Fillat P. Long-term effectiveness of corticosteroid injections for trigger finger and thumb. J Hand Surg Am 2015; 40 (1) 121-126
• 75 Mardani Kivi M, Lahiji FA, Jandaghi AB, Saheb Ekhtiari K, Hashemi Motlagh K. Efficacy of sonographically guided intra-flexoral sheath corticosteroid injection in the treatment of trigger thumb. Acta Orthop Traumatol Turc 2012; 46 (5) 346-352
• 76 Dala-Ali BM, Nakhdjevani A, Lloyd MA, Schreuder FB. The efficacy of steroid injection in the treatment of trigger finger. Clin Orthop Surg 2012; 4 (4) 263-268
• 77 Rozental TD, Zurakowski D, Blazar PE. Trigger finger: prognostic indicators of recurrence following corticosteroid injection. J Bone Joint Surg Am 2008; 90 (8) 1665-1672
• 78 Khan KM, Cook JL, Bonar F, Harcourt P, Astrom M. Histopathology of common tendinopathies. Update and implications for clinical management. Sports Med 1999; 27 (6) 393-408
• 79 Paavola M, Kannus P, Järvinen TA, Järvinen TL, Józsa L, Järvinen M. Treatment of tendon disorders. Is there a role for corticosteroid injection?. Foot Ankle Clin 2002; 7 (3) 501-513
• 80 Gaujoux-Viala C, Dougados M, Gossec L. Efficacy and safety of steroid injections for shoulder and elbow tendonitis: a meta-analysis of randomised controlled trials. Ann Rheum Dis 2009; 68 (12) 1843-1849
• 81 Osborne H. Stop injecting corticosteroid into patients with tennis elbow, they are much more likely to get better by themselves!. J Sci Med Sport 2010; 13 (4) 380-381
• 82 Labrosse JM, Cardinal E, Leduc BE , et al. Effectiveness of ultrasound-guided corticosteroid injection for the treatment of gluteus medius tendinopathy. AJR Am J Roentgenol 2010; 194 (1) 202-206
• 83 Lustenberger DP, Ng VY, Best TM, Ellis TJ. Efficacy of treatment of trochanteric bursitis: a systematic review. Clin J Sport Med 2011; 21 (5) 447-453
• 84 Gruson KI, Ruchelsman DE, Zuckerman JD. Subacromial corticosteroid injections. J Shoulder Elbow Surg 2008; 17 (1, Suppl): 118S-130S
• 85 van der Sande R, Rinkel WD, Gebremariam L, Hay EM, Koes BW, Huisstede BM. Subacromial impingement syndrome: effectiveness of pharmaceutical interventions-nonsteroidal anti-inflammatory drugs, corticosteroid, or other injections: a systematic review. Arch Phys Med Rehabil 2013; 94 (5) 961-976
• 86 Chen MJ, Lew HL, Hsu TC , et al. Ultrasound-guided shoulder injections in the treatment of subacromial bursitis. Am J Phys Med Rehabil 2006; 85 (1) 31-35
• 87 Naredo E, Cabero F, Beneyto P , et al. A randomized comparative study of short term response to blind injection versus sonographic-guided injection of local corticosteroids in patients with painful shoulder. J Rheumatol 2004; 31 (2) 308-314
• 88 Ly-Pen D, Andréu JL, de Blas G, Sánchez-Olaso A, Millán I. Surgical decompression versus local steroid injection in carpal tunnel syndrome: a one-year, prospective, randomized, open, controlled clinical trial. Arthritis Rheum 2005; 52 (2) 612-619
• 89 Marshall S, Tardif G, Ashworth N. Local corticosteroid injection for carpal tunnel syndrome. Cochrane Database Syst Rev 2002; (4) CD001554
• 90 O'Gradaigh D, Merry P. Corticosteroid injection for the treatment of carpal tunnel syndrome. Ann Rheum Dis 2000; 59 (11) 918-919
• 91 Ly-Pen D, Andréu JL, Millán I, de Blas G, Sánchez-Olaso A. Comparison of surgical decompression and local steroid injection in the treatment of carpal tunnel syndrome: 2-year clinical results from a randomized trial. Rheumatology (Oxford) 2012; 51 (8) 1447-1454
• 92 Werner RA, Andary M. Carpal tunnel syndrome: pathophysiology and clinical neurophysiology. Clin Neurophysiol 2002; 113 (9) 1373-1381