Steroid Joint Injections

Steroids are “anti-inflammatory” drugs given to patients to help reduce inflammation. These differ to steroids taken by body builders to increase muscle size and strength.

Steroids can be taken for many different reasons. Your doctor has suggested that a steroid injection may help with your joint pain. In inflammatory arthritis, such as rheumatoid arthritis, and osteoarthritis steroid injections can help to reduce inflammation. This in turn can reduce pain.

There are different types of steroids available for injection. The most common group of steroids is called cortisicosteroids and you may find doctors referring to a “Cortisone” injection. The type of cortisone used by our clinic is Depo-Medrone. In addition, we add a local anaesthetic to help relieve the initial pain from the injection.

Steroids provide powerful anti-inflammatory properties directly into the area of inflammation. This inflammation is what is causing your pain. Steroids reduce this inflammation and therefore help to reduce your pain. There are several indications for steroid injection with regard to musculoskeletal problems:

• Bursitis - such as shoulder (subacromial) or hip (trochanteric) bursitis

• Arthritis - any joint including spine for rheumatoid arthritis, gout, or osteoarthritis

• Nerve pain - such as carpal tunnel syndrome

• Tendinitis and Tenosynovitis - such as trigger finger, DeQuervain’s tenosynovitis, Tennis/Golfer’s elbow or plantar fasciitis

• Other inflammatory conditions - such as frozen shoulder, ganglion cyst, Dupuytren’s contracture

The doctor will first establish whether or not you need a steroid injection and will use the above indications as a guide.

They may want to check your blood pressure and blood sugar levels before your first injection as these can be raised following the steroid injection.

Steroid injections are usually quick and easy to perform. An “aseptic” technique may be used to ensure that the area remains clean and reduce the risk of an infection. This is done by preparing the skin with an antiseptic agent.

Once the skin is prepared your doctor will guide a needle and syringe into your joint. Although any discomfort is usually mild, this can be painful. A local anaesthetic is sometimes used to help relieve the initial pain. This will work within minutes and should wear off after approximately 30 minutes unless a longer acting anaesthetic is used. The anaesthetic may cause numbness that lasts 24 hours.

You will be advised to remain in the surgery for 20 minutes to ensure that you have not had a reaction to the medication in the injection. You may want to consider arranging transport home as any discomfort or numbness could make it difficult to drive. You should rest for 1-2 days following an injection or at the very least avoid strenuous exercise. Do not rest for too long as this could cause your joint to go to stiff. If you are having physiotherapy, then you should continue with this unless the physiotherapists advises against it. They are usually very keen to give more intensive mobilisation treatment after an injection as your joint is less painful. Make sure you inform them about having an injection so they can arrange physiotherapy around it. Keep your dressing applied for 24 hours or at least overnight following your injection.

Not all injections will relieve pain, but It is possible to repeat injections if you have found that they have helped. However, steroid injections can not be given often due to potential complications.

Joint injections are offered to patients to help them manage their pain. They can often give pain relief for several months by reducing the inflammation and swelling associated with diseases mentioned above. However, this cannot be guaranteed. You should only decide to go ahead with an injection if you feel that the benefits are worth the potential risks.

Most people have a joint injection with no side-effects. Patients usually have some discomfort at the time of the injection but most find it is not as bad as they feared.

However, no procedure is risk-free. There are always risks with any medication, including cortisone. The decision to offer you a steroid injection is not taken lightly. It is based on your signs, symptoms and past medical history, in addition to your diagnosis. Doctors will often give a trial injection when the diagnosis is not clear, and the area injected is suspected of causing your pain.

Before you decide to undergo any procedure it is essential to understand these risks. The following risks are well recognised, but there may also be risks not included in this list that re unforeseen by the doctors.

Pain

Most patients will experience discomfort during the procedure. This can be reduced if the injection contains a local anaesthetic. The local anaesthetic will usually relieve pain for 30 minutes but can cause numbness and last for 24 hours.

Some patients experience an increase in their pain (flare-up) following a injection, which can be severe and last up to 24 to 48 hours. It can occur for 1 in 10 patients. This is treated with a cold pack and anti-inflammatory medication. If you experience continuing pain and is not helped with this treatment then you should seek medical care.

There are a number of potential reasons why pain can be greater:

• the underlying inflammation is severe

• the area to be injected is severely painful

• the needle tip requires to be repositioned several times in order to distribute the cortisone effectively

• a previous bad experience has resulted in a fear of needles, or there is a general anxiety/phobia of needles and other medical procedures.

Reaction to Medicine

You may experience an allergy to any of the medications or substances used in the joint injection including cortisone, local anaesthetic, antiseptic agent or dressing. This is usually minor and self-limiting. However, some patients can have an anaphylactic reaction to the injection. Although rare this usually occurs 2 to 20 minutes after the injection. Patients are asked to remain in clinic for 20 minutes after the injection.

The cortisone may cause palpitations, hot flushes, changes to periods (in women) and mild mood disturbances which usually resolve within 24 hours without the use of any further treatment. In addition, your blood pressure or blood sugar levels may be raised for a few days, particularly in individuals who have problems with either such as patients with diabetes. Sometimes your doctor will measure these prior to your first injection and can delay your injection if they are raised.

One in 20 patients may suffer from a steroid flare. This is a reaction to the steroid and often settles on its own in 5 days. The joint can be intensely painful, red and sometimes hot. If you experience this, taking medication such as ibuprofen (if safe to do so) will help reduce the inflammation until the steroid itself works.

Up to one in 10 patients can experience facial flushing which is more common in women. It can occur within 24-48 hours after the injection. This will disappear without treatment.

Skin reaction

Some patients may have thinning of the skin or colour changes at the injection site. Sometimes nodules can form or the skin loses colour (hypopigmentation). This is especially true if stronger preparations of steroids are used. In extremely rare cases, injection into muscle can cause indentation of the skin (dimpling) at the site of injection.

As the needle will penetrate the skin, localised bleeding may occur which can form a bruise. This should resolve on its own with no treatment.

Infection

Your joint is a sterile environment. Skin acts as a natural barrier to bacteria. An injection breaks that barrier and there is a risk of introducing bacteria into the joint. This is extremely rare occurring in up one in 2000 patients, but is a serious complication. Most infections take 24 to 48 hours to manifest. If your joint becomes hot, swollen, painful and with reduced movement at 48 hours then this is considered an infection until proven otherwise. You must seek urgent medical care if you experience any of these symptoms. In addition, you may experience fevers, night sweats and feeling generally unwell.

Joint damage

Damage to the joint includes avascular necrosis (bone death). This is very rare and not proven. Joint damage may result from frequent steroid injections. Doctors usually discourage patients to have repeated and numerous injections into the same site.

Blood vessel and nerve damage

This is extremely rare and may happen only when the steroid enters the nerve sheath directly (usually only occurs with carpal tunnel injections that come quite close to the median nerve).

Cartilage or Tendon damage

Although the evidence is limited, there is some suggestion that repeated intra-articular glucocorticoid injections can result in cartilage loss. In some cases, especially if steroids are injected into tendons, tearing of the tendons can occur (tendon rupture). The risk is approximately 0.1%.

Osteonecrosis

Bone tissue destruction is an uncommon complication due to ischaemia/avascular necrosis of the bone (loss of blood to bone). The risk is reported to range from less than 0.1% to 3% however, in clinical practice it is closer to 0.1%. The severity of your joint disease may contribute more to the risk than the injection itself.

Bleeding

Local bleeding is uncommon in patients who do not have a bleeding disorder or are on blood thinners such as warfarin. Holding pressure over the puncture site with sterile gauze is typically sufficient to stop any local venous bleeding. The risk of bleeding in patients who do receive therapeutic anticoagulation is low. No change to your regime is required.

Blood sugar

The steroid can cause your blood sugar to spike. Approximately 80% of patients with diabetes have reported elevated blood sugar levels. The worse your blood sugar control is, the higher these spikes can be. Blood sugar levels usually return to normal within 5 days. Keep a close eye on your blood sugar for the first days after the injection. Monitor your sugars at least 4 times a day. Increase your insulin or medication if you need and discuss with your doctor.

Blood pressure

If you suffer from high blood pressure then your blood pressure may rise in the next few days after your steroid injection. This is often caused by fluid retention. Watch for swelling of your ankles and if you notice this then speak to you doctor. Monitor your blood pressure closely for the next 5 days after your injection. If you are concerned, speak to your doctor.

Facial flushing

Facial flushing, where the face turns red and feels warm, can be a common side effect of steroid joint injections occurring in up to 40% of patients. This occurs due to blood vessel dilation and the body's immune response to the medication. Flushing typically appears within minutes to a few hours after the injection and lasts a few hours, though it can occasionally persist for a couple of days. To manage it, stay cool, rest, and avoid triggers like hot drinks, spicy foods, and alcohol. While usually harmless, seek medical advice if flushing persists for several days or if you experience other symptoms like difficulty breathing or swelling.

Menstrual irregularity

Menstrual irregularity can be a potential side effect of steroid joint injections. These medications can affect hormonal balance, leading to changes in menstrual cycles. Women might experience changes in the timing, duration, or flow of their periods. While these irregularities are typically temporary, they can cause some inconvenience and concern. If you notice significant or prolonged changes in your menstrual cycle, it is advisable to consult your doctor to discuss your symptoms and any necessary adjustments to your treatment.

Recurrence

The steroid injection aims to relieve your pain but not permanently. Your pain may return any time within 1 week to 12 months. It is entirely possible that your the steroid injection does not relieve your pain at all. If it does work, you can repeat injections but needs to be a minimum of 3 months following any other steroid injection and a maximum of 3 injections within a year.

Joint injections are not suitable for all patients. If you have any of the following then consult your doctor before having an injection:

• Known allergy to any of the substances or medication used (either steroid or local anaesthetic)

• Infection close to the site of the proposed injection or a significant infection elsewhere

• Active rash or broken skin at the site of injection

• A tendency to bleed more readily as a result of illness or medication

• Fracture or unstable joint

• You have a prosthetic joint (joint replacement) or any metal-work

Many patients are concerned they will experience common problems associated with taking steroids such as weight gain, osteoporosis, acne, and diabetes. However, the main advantage of having an injection compared to tablets is that the dose of steroid taken remains low. Such side-effects occur when taking steroid tablets for several weeks. Therefore, it is rare for steroid injections to cause these other side-effects unless you take them more frequently (more than 3-4 times a year).

There are alternative medications you can take. Steroid injections are offered to treat pain and are therefore optional. If you feel you can manage with your pain then one option is to do nothing. You can take oral anti-inflammatory drugs such as ibuprofen or naproxen. In addition, exercise and physiotherapy can be used to treat joint pain.

Careful consideration is made if you are taking anti-coagulation medication (blood thinners) and you must discuss this with your doctor. If you are poorly controlled then you should not have an injection. However, several studies have shown no increase in risk of bleeding for patients on anti-coagulation (warfarin) even with an INR up to 4.5. The risk of suffering an adverse event if your medication is stopped far outweighs any bleeding. Therefore, we do not ask patients to stop their anti-coagulation prior to an injection.

You can take other medications and have vaccinations following a joint injection. There is no known reason to avoid alcohol following a joint injection.

There is no evidence to suggest that a steroid injection is harmful to patients who are pregnant, breastfeeding or that it affects fertility. However, you should discuss this with your doctor prior to any injection.

There is no obligation to go ahead with the procedure if you would like to explore other treatment options.

If your doctor discusses the procedure and you decide against it, you will be charged for a standard GP appointment (£100) and be refunded £50.