Intra-articular steroid injections for osteoarthritis – harmful or helpful?

Intra-articular (IA) corticosteroids are widely used treatment for pain from symptomatic knee OA. Systematic reviews show that the treatment effect is modest and lasts for 2-4 weeks on average compared with placebo (intra-articular saline). Potentially as a consequence of limited therapeutic duration, repeated injections are often given up to 4 injections annually. In this context of repeat injections, recent evidence has emerged that intra-articular corticosteroids might be associated with more cartilage loss than saline injections. Guidelines vary in the recommendation for use of IA corticosteroids. Given the frequency with which they are used, the size and scale of the population with osteoarthritis, it is critical to fully understand the benefits and merits of intra-articular corticosteroids. We have recently received commentaries from differing perspectives on this topic - join the debate, we are eager to hear your perspective.


"Effective in the short-term and safe in the long-term" is a familiar reassurance, and the context of why it seems familiar should ring alarm bells for doctors. The opioid epidemic is - perhaps - medicine's greatest failure in its history, a sin of commission not omission. We are meant to be protecting patients from harm, not causing harm, yet doctors who have prescribed high-strength opioid painkillers for non-cancer pain have inflicted enormous harm on patients. Why did we (or our colleagues) do it? Because we were falsely assured that opioids were "effective in the short-term and safe in the long-term". Doctors who prescribe opioids (ie most of us) should be forced to read Patrick Radden Keefe's Empire of Pain to gain insight into what a lie doctors were sold and how many of us believed it. Corticosteroid injections may not be as harmful in the longer-term as opioids. But the same error - in my opinion - is being made with respect to conditions like knee OA. A lack of data does not equal safety. And when long-term data starts to slowly appear and almost every study points in the same direction (that in the longer-term, you are better off having been in whatever study cohort or group did NOT get intra-articular corticosteroids) then beware. History doesn't necessarily repeat but it can rhyme. If the long-term data is not attractive for IACIs (spoiler: it's not) for a long-term chronic disease, then please do no harm and do not use.

Just to add a little more fuel to this fire......
Two studies comparing intra-articular injections used to relieve the pain of knee osteoarthritis have found that corticosteroid injections were associated with the progression of the disease compared to hyaluronic acid.
Results of both studies were presented at the annual meeting of the Radiological Society of North America.…