Are steroids right for arthritis pain?
If you have been turning to steroid injections to relieve your painful osteoarthritis, new research shows it may be riskier than previously thought.
A new study done by the Cochrane Muscular Skeletal Group and published in Radiology was done with 459 patients who were given one to three steroid injections for hip or knee arthritis. Twenty-six patients experienced a quick progression of their disease. Three patients suffered rapid joint destruction, including bone loss. Four patients had stress fractures in their hips and three had complications from osteonecrosis, which is the death of bone tissue.
The study was a follow up to a 2017 study of 140 people by Tufts Medical Center published in the Journal of American Medicine. The earlier study saw half of the participants receive a steroid shot and the other half a shot of saline solution every three months for two years. At the end of the study, those who received the steroids had a greater volume of cartilage loss and no difference in pain.
Osteoarthritis, commonly called the “wear and tear” arthritis, is the most common form of arthritis. About 30 million Americans suffer from this painful disease where the cartilage cushioning the joints breaks down or becomes damaged. That causes bone to rub against bone, which is why people feel pain. One of the common treatments for arthritis is corticosteroid injections.
The study caused a stir among patients when the news broke, said Hyannis orthopedic surgeon Jesse Affonso, MD, (three or four patients he saw that day asked him about it), but “I don’t think anything that came out in the news was groundbreaking for orthopedic surgeons.”
Appropriate Use of Steroids
While the research was educational for patients, in terms of understanding that no treatment is without potential side effects, Dr. Affonso said he is not overly alarmed by the results. On a busy day in his office, he can treat eight to 10 patients with steroid injections and his physician’s assistant administers an additional four to six.
“Steroid injections are certainly a well-utilized tool in an orthopedic surgeon’s repertoire, but you do have to be a little careful as for what they are being used for and how many injections you are giving in a particular area, either in a year or in a lifetime,” he said. “I think if you asked 10 orthopedic surgeons, you would get at least six different answers as to what orthopedic surgeons are telling their patients.”
Dr. Affonso uses steroid injections as both a diagnostic tool and a therapeutic tool. A steroid shot that works shows him where the pain is being generated. It also helps cut down on the pain patients feel. The best uses for the injections are for diseases like bursitis, tendonitis and adhesive capsulitis, which is a frozen shoulder.
Since he believes that steroid shots don’t really help people with arthritis, he refrains from treating those patients with steroids.
Most orthopedic surgeons have their own internal rules about the number of injections they are willing to give to the same joint in a year. Dr. Affonso limits it to three per year.
“If you’re giving more than three a year, it’s a sign that something else should be done, whether it is surgery, taking anti-inflammatories or living with the pain,” he said.
His specialty is shoulders, and he worries that more than three injections a year could damage the tendons surrounding the joints in the shoulder and change the intrinsic properties of the rotator cuff, which could lead to rotator cuff degeneration.
As for the number of injections over a lifetime, Dr. Affonso said that when the injections start to lose their efficacy it’s time to stop them. The hope is that the injection will buy relief from symptoms for eight to 12 weeks. Over time, with more injections, they start to lose their effectiveness and patients will feel pain again after four weeks.
But medicine is both a science and an art, and there is wiggle room on the rules, depending on the age of the patient, what the injection is for, how long the pain relief lasts and how many injections the patient has had in total. There is also the fact that some people just can’t have surgery, he said.
“We do have a patient population on the Cape that at times is either too sick to have elective surgery or who have kind of gotten too old to have elective surgery,” Dr. Affonso said. “So that’s where I will break that rule. But someone in their 50s, their 60s, their 70s that is active and is trying to stay in shape, I would say three a year. If you need more than that, then we’ve got to talk about doing something else.”
For healthy people, surgery is an obvious option, but other things can help too. Once you notice the first symptoms of arthritis, you can try to modify your activities. Losing weight is an important first step because the number one risk factor for arthritis is being overweight. When you carry extra weight, you put too much stress on your joints.
Other options are to begin an exercise routine, take anti-inflammatory medications, or there are supplements like glucosamine and chondroitin that can help.
“Physical therapy is a great first line of treatment,” Dr. Affonso said. “You can strengthen the muscles around a joint, thereby taking some of the stress off of that joint. Say your knee is hurting and you’ve developed arthritis, but perhaps it’s not significant enough for a knee replacement. You try an injection or two, see if that helps you out, go to physical therapy and try to strengthen the muscles around a joint in the hopes that that will take some of the stress off of that joint and alleviate your pain.”
Even though Dr. Affonso believes steroid injections are safe when used judiciously, there are two areas that orthopedic surgeons would never give an injection. One is the Achille’s tendon down by the ankle and the other is the triceps tendon by the back of your elbow. An injection in either of those areas can cause the tendon to rupture or become separated from the bone.
“It is well known that the risks are significantly higher in those two areas,” he said. “But other than that, injections are just one tool we use to help patients with their pain. That’s how most orthopedic surgeons use them.”