As a physio, two conversations I have on a regular basis start something like this:
“The doctor mentioned a steroid injection but I’m not sure I want it as I’ve heard they don’t always work.”
“The last steroid injection was great and lasted over a year, my pain has returned so I would like another one.”
So begs the question
Steroid injections. To jab or not to jab?
A corticosteroid injection (CSI) has traditionally been credited as a quick fix to many chronic musculoskeletal issues such as painful elbows, shoulders, hips, backs, necks, knees, you name it. Whilst short term effects appear to be beneficial, a CSI may not be addressing the root cause of the issue which in most cases is a lack of load tolerance at/around the affected area.
There is an increasing body of evidence demonstrating that treating a painful condition with a CSI is not only no longer best practice but can actually result in a worse outcome.
So what does the evidence tell us about steroid injections?
Steroid injections for elbows?
Bisset et al 2006 demonstrated that a steroid injection for lateral elbow pain (tennis elbow) had a significant benefit in the short term however post the six week mark 72% of these patients had a reported recurrence. Yes 72%! This is compared to an 8% recurrence rate for those who participated in physio and 9% reoccurrence in a wait and see approach.
Steroid injections for hips?
In gluteal tendinopathy (lateral hip pain) education and exercise has been found to be superior to the wait and see approach and steroid injections at both the 8 and 52 week mark (Mellor et al 2018). As with lateral elbow pain, steroid injections will reduce pain in the short term but this effect is reversed at the intermediate and long term (Coombes et al 2010).
Steroid injections for shoulders?
In a review of current best practice for rotator cuff related shoulder pain, Littlewood et al 2019 concluded that steroid injections should not be considered as a first line intervention. Rather management should include a few specific exercises prescribed to the patient over a minimum 12 week period. In this same population it was found that a steroid injection provided at best minimal and transient pain relief in a small number of these patients.
Steroid injections for knees and achilles?
Local steroid injections in the vicinity of the patella and achilles should be avoided due to concerns regarding potential rupture and impaired tissue repair where cell disruption is already present (Scott et al 2015).
Steroid Injections for painful hip and knee joints?
Steroid injections are commonly used for pain relief in osteo-arthritic joints especially for those who are unfit for surgery. Kompel et al 2019 have observed four main adverse joint findings in some of these patients including accelerated OA progression, subchondral insufficiency fracture, complications of osteonecrosis, and rapid joint destruction.
So what do steroid injections actually do?
At a tissue level, corticosteroids have been shown to have non-specific ion channel mediated toxicity on the human rotator cuff and significant negative effects on tendon cells in vitro including reduced cell viability, cell proliferation and collagen synthesis (Dean et al 2014). Keep in mind, physio will progressively load these areas as is current best practice so you can see how a steroid injection can be detrimental.
It is essential to consider the discomfort, cost and potential to accelerate tendon/joint degeneration when deciding whether to use steroid injection. A big reason why patients re-present with the same issue post injection has to do with their understanding. The beauty of physio is that we have ample amount of time in our consultation for the most important treatment tool in our physio basket: education.
Let’s go back to those questions
The first question is music to my physio ears as once these patients are educated with the above information they are more than happy to get stuck into their rehab. A good response to the second question is: “well if the last steroid injection worked so well, why has your pain returned?” This can often trigger the light bulb moment where a patient starts to understand. There is often a lack of understanding from the patient of what the steroid injection was for and what the real answer to fixing the problem is. I’m sure if you asked them what the long term side effects of multiple injections are, they would not know.
So when is the time to inject?
When pain and disability are so severe that it is preventing participation in exercise or when improvement with rehab has reached a plateau due to ongoing pain symptoms (Littlewood et al 2019). It is essential that the patient understands the steroid has temporary benefits and that exercise is the long term solution.
As the great Professor Bill Vicenzino said:
“if you don’t like someone cortisone is a great way to make them suffer.”
So to prevent a revolving door type scenario for musculoskeletal conditions, consider sending them to your trusty physios and podiatrists.
If you’re in need of a quality physio assessment for your musculoskeletal pain you can book in with our great team of physiotherapists in Pascoe Vale here.
If you have lower limb pain then our podiatry team will be able to help you out here.
