Max Sun MD FRCPC (biography, no disclosures)
What I did before
Osteoarthritis of the knee is a prevalent problem in Canada and the United States (1,2). Previous studies have shown that osteoarthritis does have an inflammatory component and studies have specifically indicated inflammation of the synovium of osteoarthritic joints (3). Thus, it is theorized that steroid injection into the osteoarthritic knees can help decrease the inflammation, and therefore decrease pain and progression.
There have been numerous studies on intraarticular steroid injections for knee osteoarthritis with a Cochrane review showing benefits up to 3 weeks, but minimal benefits after 3 weeks (4). Some studies in the past have warned about increased risk of perioperative hip replacements, if done within 3 months of a steroid injection (5,6). However, this remains somewhat controversial as other studies do not show any significant increased risk (7). Some have suggested that total hip replacements should not be performed within three months of a intraarticular steroid injection (8 [Schairer 2016], 9 [Werner 2015]).
There have been other concerns about the use of local anaesthetic and its chondral toxicity. Local anaesthetic including lidocaine and bupivacaine have been shown to be cytotoxic to the chondrocytes with potential risk to joint cartilage in in vivo studies. However, with lack of effective conservative therapies for joint osteoarthritis, we are left with certain interventional procedures that may give the patient some short term relief while allowing them to perform further exercise and decrease their joint pain through physiotherapy. Previous studies on the adverse effects of intraarticular steroid injection on joint cartilage have not shown any complications, but the studies were limited as they used x-rays to evaluate progression of osteoarthritis (10 [McAlindon, reference 13]). Radiographs are insensitive to picking up osteoarthritis progression. Any underlying joint damage would have to have progressed to be detected on x-rays. Concerns of cartilage damage were further exacerbated by the known anti-anabolic effects of steroids on the cartilage (11 [McAlindon, reference 12]). Additionally, there is a significant placebo effect with intraarticular joint injections of saline and other non anti-inflammatory substances. (12 [McAlindon, reference 36]). Thus, while we were assuming that regular intraarticular steroid injections were beneficial there has never been a study to compare these treatment regimens.
What changed my practice
The current study by McAlindon et al. published in Jama, 2017 (10), was a randomized placebo-controlled double-blinded trial lasting two years. One group of patients received triamcinolineinjections every three months while the others received saline. The studies reported that there was demonstrable decrease in the cartilage thickness on MRI testing in the steroid injection group compared to the saline group, although there was no difference in their improvement from pain and function. This study highlights the risks of regular steroid therapy and also reinforces the fact that patients can have a response from saline injections.
What I Do Now
Even though the study did not show any difference in effect between the steroid injection group and the placebo group, it does not mean that there is no benefit from intraarticular injections. It seems that intraarticular injection of either substance can cause decreasing pain and increasing function although there is no significant difference between the two groups. Within the two groups, we are much more able to detect cartilage damage compared to performing x-rays.
Since this study has come out, I have decreased my frequency of steroid injections to the knee and also to the hip. While the knee joint is slightly different type of a joint compared to the hip, I do extrapolate and believe that steroid hip injections would also be limited in their value, specifically since there is a lack of evidence on significant long term benefit in systematic reviews thus far.
In patients with osteoarthritis of the knee, I now try less invasive therapies including hot compress, antiinflammatory creams, weight loss, and using the TENS machine, along with trigger point injections to help decrease their pain associated with joint degeneration (13). Personally I find ketoprofen more effective than diclofenac creams. The maximum dosage for ketoprofen cream can be up to 20%. If I sense they have an aspect of neuropathic pain over the knee joint, I also add lidocaine 5% mixed in with the anti-inflammatory cream as well. The role of acupuncture in treatment of knee osteoarthritis is still uncertain although some studies do show some benefit (14). It is relatively safe so it is something I occasionally recommend.
I have also prescribed certain knee braces, sleeves, and orthotics as conservative management of the knee OA. There is some fair quality of evidence on the effectiveness of these interventions. Additionally, I recommend using a walking cane to increase stability and relief of osteoarthritic knee pain due to decreased weight bearing (14).
Physiotherapy is still the main treatment for these patients. For patients who seek out steroid injections, I educate them on the results of the study and emphasize muscle strengthening (14). Specifically, water-based exercises and weight bearing exercises for muscle strengthening have good benefits for knee osteoarthritis (14). I also advise weight loss because it can also decrease pain symptoms (14). Tai chi has also been found to be useful in treatment of knee osteoarthritis. This is likely due to a combination of muscle strengthening, body weight based exercises, and increased proprioception of the joint which decreases instability (15).
TENS treatment is also quite safe. Evidence for TENS treatment is lacking but from my personal experience, it can certainly help patients with muscle spasms and pain from osteoarthritis (14).
Hylauronic acid injections also lack substantial evidence in large randomized placebo-controlled trials, although smaller trials do indicate potential benefits (4). So far, the risks of cartilage damage has not been associated with intraarticular hylauronicacid injections. There is no limit as to how frequently it can be performed.
Oral medications such as chondroitin supplements are usually not recommended as there is no evidence for improvement of knee degeneration with oral supplements and evidence of pain relief is lacking (14). However, the supplements are usually quite safe and if the patient is insistent on taking these medications, I usually allow them to continue. Opioid therapy should not be used long term for knee osteoarthritis. Opioid therapy shows some evidence for short-term relief but lacks evidence for long-term treatment of knee osteoarthritis and can be associated with various side effects (14).
In patients who have a severe flare of osteoarthritis, especially with swelling and warmth, I do still consider steroid injections, as I believe there is a significant inflammatory component to their joint osteoarthritis that may benefit from steroid injections. I would usually advise steroid injections no more frequently than once every 3-4 months and not less than 3 months prior to knee replacement surgery.
In patients without such inflammatory findings, I am less inclined to use steroid injections. If they are insistent on an injection, I do offer them the option of undergoing hylauronic acid supplementation injection more often now, but I also always educate patients that the evidence is weak and the cost is high. Some studies do show mild pain relief in the placebo arm with injection of saline solution into the joint. We do know that saline injections are never a real placebo and it can have some pain relief properties but it is not something I usually perform.
Overall, all interventional procedures are but a temporizing measure. Quadriceps and hip abductor strengthening is the best long term solution for knee osteoarthritis, although if a patient has a severe pain flare, I still believe steroid injection is a reasonable temporizing measure to help encourage these patients to increase their exercise regimen and functional capacity.
- Lawrence RC, Felson DT, Helmick CG, et al. National Arthritis Data Workgroup. Estimates of the prevalence of arthritis and other rheumatic conditions in the United States, part II. Arthritis Rheum. 2008;58(1):26-35. DOI: 10.1002/art.23176. (View)
- Statistics Canada. Prevalence of osteoarthritis, by age group and site of joint pain, household population aged 20 or older diagnosed with arthritis, Canada excluding territories, 2009. Modified November 27, 2015. Accessed January 10, 2019. (View)
- Berenbaum F. Osteoarthritis as an inflammatory disease (osteoarthritis is not osteoarthrosis!). Osteoarthritis Cartilage. 2013;21(1):16-21. DOI: 10.1016/j.joca.2012.11.012. (View)
- Juni P, Hari R, Rutjes AWS, et al. Intra-articular corticosteroid for knee osteoarthritis. Cochrane Database Syst Rev. 2015;10:CD005328. DOI: 10.1002/14651858.CD005328.pub3. (View with CPSBC or UBC)
- Ravi B, Croxford R, Hollands S, Hawker GA. The relationship between pre-surgical intra-articular injection and risk for early revision and infection following total hip arthroplasty. Osteoarthritis Cartilage. 2013;21(Suppl):S10. DOI: 10.1016/j.joca.2013.02.042. (View with CPSBC or UBC)
- McIntosh AL, Hanssen AD, Wenger DE, Osmon DR. Recent intraarticular steroid injection may increase infection rates in primary THA. Clin Orthop Relat Res. 2006;451:50-54. DOI: 10.1097/01.blo.0000229318.51254.79. (View with CPSBC or UBC).
- Pereira LC, Kerr J, Jolles BM. Intra-articular steroid injection for osteoarthritis of the hip prior to total hip arthroplasty. Bone Joint J. 2016;98-B:1027–1035. DOI: 10.1302/0301-620X.98B8.37420. (Request with CPSBC or view with UBC)
- Schairer WW, Nwachukwu BU, Mayman DJ, Lyman S, Jerabek SA. Preoperative hip injections increase the rate of periprosthetic infection after total hip arthroplasty. J Arthroplasty. 2016;31(9 Suppl):166–169 e1. DOI: 10.1016/j.arth.2016.04.008. (View with CPSBC or UBC)
- Werner BC, Cancienne JM, Browne JA. The timing of total hip arthroplasty after intraarticular hip injection affects postoperative infection risk. J Arthroplasty. 2016;31(4):820-823. DOI: 10.1016/j.arth.2015.08.032. (View with CPSBC or UBC)
- McAlindon TE, Bannuru RR, Sulivan MC, et al. OARSI guidelines for the non-surgical management of knee osteoarthritis. Osteoarthritis Cartilage. 2014;22(3):363-388. DOI: 10.1016/j.joca.2014.01.003. (View)
- 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. DOI: 10.1002/art.10777. (Request with CPSBC or view with UBC)
- Wernecke C, Braun HJ, Dragoo JL. The effect of intra-articular corticosteroids on articular cartilage: a systematic review. Orthop J Sports Med. 2015;3(5):2325967115581163. DOI: 10.1177/2325967115581163. (View)
- Altman RD, Devji T, Bhandari M, Fierlinger A, Niazi F, Christensen R. Clinical benefit of intra-articular saline as a comparator in clinical trials of knee osteoarthritis treatments: a systematic review and meta-analysis of randomized trials. Semin Arthritis Rheum. 2016;46(2):151-159. DOI: 10.1016/j.semarthrit.2016.04.003. (View)
- Derry S, Conaghan P, Silva JAPD, Wiffen PJ, Moore RA. Topical NSAIDs for chronic musculoskeletal pain in adults. Cochrane Database Syst Rev. 2016;4:CD007400. DOI: 10.1002/14651858.CD007400.pub3. (View with CPSBC or UBC)
- Hochberg MC, Altman RD, April KT, et al. American College of Rheumatology 2012 recommendations for the use of nonpharmacologic therapies in osteoarthritis of the hand, hip, and knee. Arthritis Care Res. 2012;64(4):465-474. DOI: 10.1002/acr.21596. (Request with CPSBC or view with UBC)