Risks and Considerations of Corticosteroid Injections for Joint Pain

Introduction to Risks

Quarterly corticosteroid injections for joint pain carry significant risks, including immunosuppression with increased infection risk, hyperglycemia, decreased bone mineral density, hypothalamic-pituitary-adrenal axis suppression, and potential acceleration of cartilage degeneration with repeated use, as reported by the Annals of the Rheumatic Diseases guidelines 1, 2
Secondary adrenal insufficiency can last 4 weeks to 2 months after injection, according to the American College of Rheumatology 1

Decreased bone mineral density with possible increased fracture risk is associated with repeated injections, as recommended by the American Geriatrics Society 3
Hypothalamic-pituitary-adrenal (HPA) axis suppression is a potential risk, as reported by the American College of Rheumatology 3

Pain, soreness, and exacerbation of symptoms at the injection site are common complications, with vasovagal reactions reported in 2.5% of patients, facial flushing, and sweating, as well as transient sciatic nerve block if injection leaks into surrounding tissues 3
Joint infection (septic arthritis), spinal epidural abscess, meningitis, and endocarditis are potential complications, particularly in immunosuppressed patients, with a reported infection rate of 0.6% (1 in 625 injections) for injections into prosthetic joints, as recommended by the Annals of the Rheumatic Diseases guidelines 3, 2

The American Geriatrics Society recommends considering alternative non-steroid therapies for long-term management, and current pain management guidelines recommend non-pharmacologic therapies (physical therapy, weight loss for knee osteoarthritis) or non-steroid pharmacologic options (acetaminophen, NSAIDs) for patients requiring long-term pain management, as suggested by the American College of Rheumatology 4, 5, 2
The American College of Rheumatology strongly recommends against PRP treatment for knee and hip OA due to inconsistent evidence, citing concerns about heterogeneity in PRP preparations and variable techniques used for injection, with an estimated risk of infection following PRP joint injections of 0.035% (approximately 3 per 7,900 procedures) 6, 2

Strict aseptic technique is recommended, including the use of surgical gloves, skin preparation with alcohol, iodine disinfectant, or chlorhexidine, and changing needles between drawing the product and injecting it into the joint, as recommended by the American College of Rheumatology 2
Post-procedure care should include avoiding overuse of injected joints for 24 hours following injection, and complete immobilization is not recommended, with management of complications typically involving rest, ice, and over-the-counter analgesics, and prompt joint aspiration for cell count, culture, and immediate referral for possible surgical intervention if infection is confirmed, as well as early antibiotic therapy, as suggested by the American College of Rheumatology 2

Diabetic patients may experience transient hyperglycemia, particularly from day 1-3 post-injection, and should monitor glucose levels for 3 days after injection, as reported and recommended by the Annals of the Rheumatic Diseases guidelines 2
Injections into prosthetic joints should be avoided in routine practice, and if necessary, should be performed by orthopedic surgeons after strict screening for prosthetic infection, as recommended by the Annals of the Rheumatic Diseases guidelines 2
A generally accepted guideline is to avoid more than 3-4 cortisone injections in the same joint per year, as suggested by the Annals of the Rheumatic Diseases guidelines, and to wait at least 3 months between injection and joint replacement surgery to minimize infection risk, with the highest risk when surgery occurs within 2-4 weeks after injection 2