Risks of Cortisone Injections for Knee Pain

Cortisone is not your knees friend

Cortisone injections or corticosteroid injections more generally, have been around since the early 1950’s to treat various conditions including knee pain.  Initially, cortisone was viewed as a major medical breakthrough to treat arthritic and inflammatory conditions that were not well managed through drugs on the market at the time.  Now, over 70 years later we have a plethora of evidence of what benefit they provide as well as the risks, side effects, and poor long term outcomes.  

Dangers of Cortisone Injections for the Knee Joint

Cortisone is not inherently bad, but you must fully understand what you’re getting yourself into when you elect to have a doctor inject it into your knee.  Steroid injections have become increasingly common and readily recommended and available throughout primary care, family medicine, orthopedic, and pain management clinics throughout the United States and world.  Despite being routinely utilized, steroid injections are actually not a first line therapy for knee osteoarthritis (OA).  Meaning, physicians should try various other treatments before even considering a steroid shot.  Current clinical guidelines in the US, according to UpToDate, state “We recommend against routine use of intraarticular glucocorticoid injections for patients with knee OA. We limit the use of intraarticular injections to patients with moderate to severe pain and contraindications to or failure of other treatment options who are seeking short-term pain relief.”¹  Basically, doctors should not give steroid injections like cortisone unless the patient is in significant pain and has tried and failed all other options and only is looking for short term relief.  Does that sound good to you?  

What are the Risks and Side Effects of Cortisone Injections?

  • Increased blood sugar
  • Infection
  • Temporary spike in pain (Cortisone Flare)
  • Loss of knee cartilage
  • Weakening of soft tissue of the knee
  • Tendon rupture
  • Osteoporosis (thinning of bone)
  • Osteonecrosis (death of bone)

arthritic knee pain worse after multiple cortisone shots

Does Cortisone relieve Knee Pain?

The answer to this depends on whether we are looking at short term pain relief or long term knee pain relief.  A recent very large research study that compiled data from over 30 different randomized controlled trials of various non-surgical knee injections provided clear insight to this question.  The examined 3,463 patients with knee pain who either received placebo injection, corticosteroid injection, hyaluronic acid injection (HA) aka “gel shots” or platelet rich plasma injection.  The patients completed a comprehensive baseline pain and joint function assessment followed by routine follow ups at 3-months, 6-months, and 12-months across all these studies.  How did cortisone do?  Well, at the 3-month follow up placebo was better than steroids.  At the 6-month follow up corticosteroids were the third best treatment option with PRP and hyaluronic acid outperforming.  Finally, at the 12-month follow up, corticosteroids were the worst treatment option of the 4 evaluated with placebo once again being better.²  So what does this mean?  Well it’s not good news for steroids as they failed to show substantial pain relief at various follow up checks.  So we know steroid injections do not work long term for knee pain/arthritis.  They may have some effect and pain reduction in the very short term, less than 3 months, but by the time the researchers evaluated them, the pain relief was already gone.  

knee surgery after years of cortisone injections

Steroid Injections lead to Knee Replacement

This can not be more clearly stated.  Once you go down the routine cortisone / steroid injection route, you’re stuck on the track that leads to total knee replacement or knee arthroplasty.  For some people that’s fine and they can accept this, for others they had no clue that this was what they signed up for.  We have some recent data published in The Bone and Joint Journal that examined the long term effects of corticosteroid injections.  They found that patients who had steroid injections have had much higher rates of ultimately needing total knee replacement surgery than those who did not have injections.  Over a series of 9 years they found people have a 9.4% increase in absolute risk of total knee replacement surgery per steroid injection they received.³  You might want to read that again.  This mirrors what I see daily in clinical practice and provides quite proof that steroids lead you to surgery whether you like it or not.  

Why do people keep getting Cortisone injections?

We’re had steroids around for a very long time and doctors have used them for many decades for knee pain.  We have more data and research than ever before demonstrating poor outcomes and enhanced cartilage destruction of the knee joint with steroids.  This leads us to ponder why patients and doctors keep electing to use corticosteroids for knee pain/arthritis?  Unfortunately, I do not know the exact answer to this but imagine various factors are at play that all contribute.  Steroid injections have been in medicine for a long time and are a part of every doctor’s medical education.  Physicians who do not stay up to date on the latest literature may default into using steroid injections.  Clinics and doctors get reimbursed almost 100% of the time they perform a steroid injection, so there is an obvious financial incentive at play.  From the patients side of things, their insurance covers the treatment and their out of pocket expense is minimal.  So in the short term, it’s a win win for both parties, but in the long term it’s a massive loss for the patient’s deteriorating knee joint.  Once again, I cannot state the exact answer to this question and am only speculating and reporting what I have seen in clinical practice.  

Additional Resources

 

 

 

 

 

 

 

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Author:

Dylan Krueger, NMD

Atlas Health Medical Group

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References:

1. Deveza L, Bennell K. UpToDate. uptodate.
2. Migliorini F, Driessen A, Quack V, et al. Comparison between intra-articular infiltrations of placebo, steroids, hyaluronic and PRP for knee osteoarthritis: a Bayesian network meta-analysis. Arch Orthop Trauma Surg. 2021;141(9):1473-1490.
3. Wijn SRW, Rovers MM, van Tienen TG, Hannink G. Intra-articular corticosteroid injections increase the risk of requiring knee arthroplasty. Bone Joint J. 2020;102-B(5):586-592.

 

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