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The injection of corticosteroids (hereafter referred to as steroids) into the knee joints of patients with osteoarthritis of the knee is a widespread practice, but the evidence that such injections benefit these patients is highly questionable. Results of a recent clinical trial published in the Journal of the American Medical Association (JAMA) in May 2017 indicated that steroid injections do not reduce knee pain or signs of knee joint degeneration and may actually accelerate the...
The injection of corticosteroids (hereafter referred to as steroids) into the knee joints of patients with osteoarthritis of the knee is a widespread practice, but the evidence that such injections benefit these patients is highly questionable. Results of a recent clinical trial published in the Journal of the American Medical Association (JAMA) in May 2017 indicated that steroid injections do not reduce knee pain or signs of knee joint degeneration and may actually accelerate the breakdown of joint cartilage.
Knee osteoarthritis
Knee osteoarthritis is a condition in which the cartilage in the knee joint degrades over time, usually due to a gradual “wear-and-tear” process through repeated use. Symptoms of this condition include pain, stiffness, swelling and difficulty in bending the knee and walking.
Risk factors for knee osteoarthritis include older age, obesity, a history of knee injury, certain occupations (such as those that require standing for long periods), and, in some cases, genetic or inborn bone or joint deformities.[1] In one study, 45% of adults developed symptomatic knee osteoarthritis by age 85, with the risk rising with increasing weight.[2]
Review of prior clinical trials
In 2015, a comprehensive review of all controlled clinical trials comparing steroid knee injections with either a “sham” (no treatment) injection or no injection in patients with knee osteoarthritis was published by the Cochrane Database of Systematic Reviews.[3] A total of 1,767 subjects were enrolled across the 27 reviewed trials.
The review’s authors noted that the quality of the evidence overall was low due to poor and potentially biased trial designs. The review found that steroid injections reduced knee pain and increased knee functioning somewhat in the first few weeks after an injection but that these “small” to “moderate” effects waned by approximately three months and disappeared by six months after injection. Furthermore, steroid injections did not improve quality of life or have beneficial structural effects on the knee joint.
The authors concluded that there were no long-term benefits of steroid injections for knee osteoarthritis and that the evidence for even the minor, short-term benefits on pain and knee functioning was uncertain given the low quality of the studies.
The JAMA trial[4]
The trial was conducted by researchers in Boston from June 2011 to January 2015 and was funded by the National Institutes of Health. The researchers randomly assigned 140 adults with knee osteoarthritis to receive knee injections of steroids or of salt water. Subjects received the injections every three months for two years. To minimize the potential for bias, neither the researchers nor the subjects knew which subjects were given steroid injections and which were given salt-water injections.
At the start of the trial and every three months thereafter for two years, the subjects completed questionnaires that assessed knee pain and stiffness and the ability to perform daily activities. The subjects also underwent MRI scans of the knees to assess knee cartilage damage at the start of the trial and then annually for two years.
After two years, the researchers found no significant differences between the two groups in knee pain or stiffness or in the ability to perform daily activities. However, steroid injections did cause greater cartilage loss and damage in the knees than salt-water injections.
The lack of any long-term symptom relief and the accelerated cartilage damage and loss led the study’s authors to conclude that these “findings do not support [steroid injections] for patients with symptomatic knee osteoarthritis.”[5]
What You Can Do
If you have been diagnosed with knee osteoarthritis, you should first try non-pharmacological approaches to treat your condition. First, if you are overweight or obese, you should begin a healthy weight-loss program.[6] Regardless of your weight, you also should begin a physical therapy and exercise program tailored to your abilities, which can include swimming, aerobic walking and tai chi. In some cases, you may require special footwear.
If none of these approaches relieves your symptoms, then you can try over-the-counter pain relievers, such as aspirin (BAYER, DURLAZA, EXCEDRIN), non-steroidal antiinflammatory drugs (ibuprofen [ADVIL] or naproxen [ALEVE]) or acetaminophen (TYLENOL). If none of these approaches works and your pain or diminished knee function is severe, then you should discuss with your health care provider whether you would be a candidate for knee replacement surgery.
References
[1] Mayo Clinic. Osteoarthritis: Symptoms and causes. http://www.mayoclinic.org/diseases-conditions/osteoarthritis/symptoms-causes/dxc-20198250. Accessed September 5, 2017.
[2] Murphy L, Schwartz TA, Helmick CG, et al. Lifetime risk of symptomatic knee osteoarthritis. Arthritis Rheum. 2008;59(9):1207-1213.
[3] Jüni P, Hari R, Rutjes AW, et al. Intra-articular corticosteroid for knee osteoarthritis. Cochrane Database of Systematic Reviews 2015, Issue 10. Art.No.:CD005328. DOI: 10.1002/14651858.CD005328.pub3.
[4] McAlindon TE, LaValley MP, Harvey WF, et al. Effect of intra-articular triamcinolone vs saline on knee cartilage volume and pain in patients with knee osteoarthritis: A randomized clinical trial. JAMA. 2017;317(19):1967-1975.
[5] Ibid.
[6] Hochberg MC, Altman RD, April KT, et al. American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee. Arthritis Care Res (Hoboken). 2012;64(4):465-474.
