Therapeutic Corticosteroid Injection

Original Editor - Maëlle Cormond

Top Contributors - Maëlle Cormond, Lucinda hampton, Kim Jackson, Claire Knott and Wanda van Niekerk - Maëlle Cormond, Fien Maesschalck, Mariska Tjeerdsma, Vicky van Genechten

Therapeutic Corticosteroid Injections - overview

Cortisone injections can help relieve pain and inflammation in a localised area of the body. They're most commonly injected into joints — such as the ankle, elbow, hip, knee, shoulder, spine, wrist and small hand or foot joints[1].

The injections usually contain a corticosteroid medication and a local anaesthetic. Corticosteroids are medications that mimic the effects of the hormone cortisol, produced naturally by the adrenal glands. Cortisol affects many parts of the body, including the immune system. Corticosteroids helps lower levels of prostaglandins and reduce the interaction between certain white blood cells (T-cells and B-cells) involved in the immune response. Corticosteroids stimulate this effect to lessen the inflammatory response.[2]

Because of potential side effects, the number of injections you can get in a year generally is limited.

[3]

Conditions/Areas commonly treated

bursa in shoulder

Examples of conditions for which local cortisone injections are used include inflammation of a bursa, (bursitis of the hip, knee, elbow, or shoulder), a tendon (tendinitis such as tennis elbow), and a joint (arthritis). Knee osteoarthritis, hip bursitis, painful foot conditions such as plantar fasciitis, rotator cuff tendinitis, frozen shoulder, and many other conditions may be treated with cortisone injections.

Corticosteroids in the treatment of specific regions

Lateral Epicondylitis

Expert opinion is already turning away from corticosteroids for tennis elbow in response to mounting evidence that the injections don’t work for long and encourage recurrences. [4]

In a study from Brooke K et al. corticosteroid injection resulted in lower complete recovery or much improvement at 1 year vs placebo injection and greater 1-year recurrence. Among patients with chronic unilateral lateral epicondylalgia, the use of corticosteroid injection vs placebo injection resulted in worse clinical outcomes after 1 year, and physiotherapy did not result in any significant differences. [4]

Krogh TP et al declare that neither injection of PRP nor glucocorticoid was superior to saline with regard to pain reduction in LE at the primary end point at 3 months. However, injection of glucocorticoid had a short-term pain-reducing effect at 1 month in contrast to the other therapies. Injection of glucocorticoid in LE reduces both color Doppler activity and tendon thickness compared with PRP and saline. [5]

Other articles refer to different kind of methods of injections.

Okçu G et al found that long-term clinical success in the treatment of lateral epicondylitis depends on the injection method. The peppering technique appears to be more effective than the single injection technique in the long-term. Group 1 received a single injection of 1 ml betamethasone and 1 ml prilocaine on the lateral epicondyle at the point of maximum tenderness. Group 2 patients received an injection of the same drug mixture. Following the initial injection, the needle tip was redirected and reinserted down the bone approximately 30 to 40 times without emerging from the skin, creating a hematoma. [6]

Stefanou A et al. compares corticosteroid injection to corticosteroid iontophoresis for lateral epicondylitis. It accurse that the corticosteroid iontophoresis is a better treatment for lateral epicondylitis that the corticosteroid injections. The iontophoresis patients had statistically significant improvement in grip strength at the conclusion of hand therapy compared with baseline. They were also more likely to get back to work without restriction. By 6-month follow-up, all groups had equivalent results for all measured outcomes. Dexamethasone via iontophoresis produced short-term benefits because for this group grip strength and unrestricted return to work were significantly better. This study suggests that this iontophoresis technique for delivery of corticosteroid may be considered a treatment option for patients with lateral epicondylitis. [7]

In a study from Nilsson P et al. the intervention group had less pain than patients treated with corticosteroid injections (p < 0.0001) or NSAIDs (p = 0.048) and experienced better function than those treated with corticosteroid injections (p = 0.002). The intervention group had a lower recurrence (p < 0.0001) and fewer sick leave days at the time of the visit to the health care centre (p = 0.005). [8]

We can decide that the most articles are not very promising about the corticoid injections. Other treatments may have better results. Most studies found good results in short term (pain release), however corticoid injections seem not to be effective in long term.

Shoulder

In tendonitis of the shoulder a meta analysis of studies found that cortisone injections are well tolerated and more effective for tendonitis in the short-term than pooled other treatments, though similar to NSAIDs. No long-term benefit was shown.[9]

A 2004 Cochrane review found that despite many RCTs of corticosteroid injections for shoulder pain, their small sample sizes, variable methodological quality and heterogeneity means that there is little overall evidence to guide treatment. Subacromial corticosteroid injection for rotator cuff disease and intra-articular injection for adhesive capsulitis may be beneficial although their effect may be small and not well-maintained.[10] 

A 2005 meta analysis found that subacromial injections of corticosteroids are effective for improvement for rotator cuff tendonitis up to a 9-month period. They are also probably more effective than NSAID medication.[11]

Knee

A 2004 meta analysis of studies highlights that in OA Intra-articular corticosteroids provide short term (two weeks) relief of symptoms of osteoarthritis of the knee, noting that multiple injections may be damaging the articular cartilage. Intra-articular corticosteroids are probably effective in improving symptoms of osteoarthritis of the knee for 16 to 24 weeks.[12]

Hip

In the setting of OA, corticosteroids appear to be the most effective, providing significant pain relief for up to 12 weeks. Howver thay show little benefit for labral tears or femoroacetabular impingement.[13]

Plantar Heel Pain

A 2017 Cochrane review found little to recommend about cortisone injections concluding remarks being "We found low quality evidence that local steroid injections compared with placebo or no treatment may slightly reduce heel pain up to one month but not subsequently... Where available, the evidence from comparisons of steroid injections with other interventions used to treat heel pain and of different methods of guiding the injection was also very low quality. Although serious adverse events relating to steroid injection were rare, these were under‐reported and a higher risk cannot be ruled out".

Conclusion

Cortisone injections should be used in conjunction with physical therapy eg to treat rotator cuff syndrome and impingement syndrome. The cortisone injection will offer pain relief and allows a window of opportunity to begin appropriate rehabilitation of the involved area (note - the first 24 hours following an injection the area should have minimal movement to allow the cortisone to bathe the intended area). If the client feels the injection is a cure they will find when the injection wears off they may be worse than before as they have not done the appropriate rehabilitation. Educate your clients and rehab well after cortisone injections are given and the outcome appears to be the best.

References

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  1. Mayo Clinic Cortisone shots available from: https://www.mayoclinic.org/tests-procedures/cortisone-shots/about/pac-20384794 (last accessed 25.9.2019)
  2. Arthritis Foundation Use of Corticosteroids in Osteoarthritis Available from: https://www.arthritis.org/living-with-arthritis/treatments/medication/drug-types/corticosteroids/corticosteroid-injections.php (last accessed 25.9.2019)
  3. Sportology feb 2015 Cortisone Basics: The Lowdown from the Expert - Dr. Hamid Available from: https://www.youtube.com/watch?v=QmMGwQb8lig&app=desktop (last accessed 25.9.2019)
  4. 4.0 4.1 Coombes B.K. et al. Effect of Corticosteroid Injection, Physiotherapy, or Both on Clinical Outcomes in Patients With Unilateral Lateral Epicondylalgia, A Randomized Controlled Trial, 2013, JAMA. Level of evidence: 1b
  5. Krogh TP et al. Treatment of lateral epicondylitis with platelet-rich plasma, glucocorticoid, or saline: a randomized, double-blind, placebo-controlled trial,2013, Diagnostic Centre, Region Hospital Silkeborg, Silkeborg, Denmark. Level of evidence: 1b
  6. Okçu G et al. Evaluation of injection techniques in the treatment of lateral epicondylitis: a prospective randomized clinical trial, 2012, Department of Orthopedics and Traumatology, Faculty of Medicine, Celal Bayar University, Manisa, Turkey. Level of evidence: 1b
  7. Stefanou A et al., A randomized study comparing corticosteroid injection to corticosteroid iontophoresis for lateral epicondylitis, 2012, Department of Surgery, Henry Ford Hospital, Detroit, MI 48202, USA. Level of evidence: 2b
  8. Nilsson Pet al., Lateral epicondylalgia: a structured programme better than corticosteroids and NSAID,2012 ,Tandemkliniken, Tvååker Primary Health Care Centre, Varberg, Sweden. Level of evidence: 1b
  9. 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. Annals of the rheumatic diseases. 2009 Dec 1;68(12):1843-9. Available from: https://ard.bmj.com/content/68/12/1843 (last accessed 25.9.2019)
  10. Buchbinder R, Green S, Youd JM. Corticosteroid injections for shoulder pain. Cochrane Database of Systematic Reviews. 2003(1). Available from: https://www.ncbi.nlm.nih.gov/pubmed/12535501 (last accessed 25.9.2019)
  11. Arroll B, Goodyear-Smith F. Corticosteroid injections for painful shoulder: a meta-analysis. Br J Gen Pract. 2005 Mar 1;55(512):224-8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/15808040 (last accessed 25.9.2019)
  12. Arroll B, Goodyear-Smith F. Corticosteroid injections for osteoarthritis of the knee: meta-analysis. Bmj. 2004 Apr 8;328(7444):869. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC387479/ (last accessed 25.9.2019)
  13. Chandrasekaran S, Lodhia P, Suarez-Ahedo C, Vemula SP, Martin TJ, Domb BG. Symposium: evidence for the use of intra-articular cortisone or hyaluronic acid injection in the hip. Journal of hip preservation surgery. 2015 Mar 31;3(1):5-15. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4808252/ (last accessed 25.9.2019)