Injections: The Dark Side
“If only you knew the power of…The Injection!”
Wait…that’s not right. But you get where we’re going with this.
This blog covers common injections used for musculoskeletal conditions. We will focus on corticosteroid and NSAID (non-steroidal anti-inflammatory drug) injections, discussing their potential side effects and whether or not they are effective.
Both types of injections are commonly used as “conservative” treatments for many musculoskeletal conditions. However, the use of these injections may not be what’s best for your condition, and in some cases, they COULD CAUSE MORE HARM THAN GOOD.
General Information
Corticosteroid and NSAID injections are used to treat musculoskeletal conditions like tendinopathy, ligament sprains, bursitis, osteoarthritis, spinal conditions, muscle strains, etc. Corticosteroids include hydrocortisone, methylprednisolone, dexamethasone, betamethasone, prednisolone, triamcinolone, etc. Common NSAIDs include ibuprofen, naproxen, diclofenac, celecoxib, mefenamic acid, etoricoxib, and indomethacin.
Sheesh, what a mouthful.
How do they work?
Most NSAIDs work by blocking cyclooxygenase (Cox), which allows for the production of prostaglandins. They are an important hormone involved in the inflammatory process. Conversely, corticosteroids mimic the hormone cortisol and bind to certain receptors to “turn off” inflammatory genes that have been activated in the inflammatory process. Simply put, both medications REDUCE THE INFLAMMATORY RESPONSE that occurs during/after injury, illness, infection, etc.
Inflammation isn’t part of the Dark Side like you think…
As I’ve mentioned in a previous post, acute inflammation is necessary for appropriate healing and recovery from an injury or surgery. When you injure a tissue like bone, muscle, tendon, etc. your body reacts with an initial inflammatory response. This response helps to remove the damaged tissue and replace it with healthy tissue over time. Unfortunately, this process often causes high levels of pain and, at times, gets out of control. In this case, NSAIDs and corticosteroids might be used to reduce pain and decrease the intensity of the inflammatory response. However, this may alter the natural healing process and cause longer healing times. When inflammation and pain transition to a chronic state, these treatments are good options. Unfortunately, they could still come with unwanted side effects and/or results.
In acute situations, anti-inflammatory treatments should generally be avoided as using them in the early stages of an injury/surgery can impair recovery. However, that’s a blog post for another time.
How often are they used?
3 surveys showed that:
17 million Americans consumed NSAIDs daily¹
Approximately 50 million use NSAIDs intermittently or routinely throughout the year¹
30 million elderly people took NSAIDs on a regular basis¹
90 out of 400 surgeons used steroid injections in the treatment of their patients, administering an average of 193 extra-articular injections yearly²
And, the numbers above are from surveys that are over 25-YEARS-OLD. Therefore, you can safely assume these numbers have increased. Also, a survey of American football players showed that 1 in 7 high school athletes took NSAIDs daily and 29% of college athletes took them as a preventive measure on the day of a game.³
How are they injected?
Your condition, doctor’s practice habits, available equipment, etc. all affect how they’re injected. To keep it simple, we’ll narrow it down to two types of injection: extra-articular and intra-articular. EXTRA-articular means the injection is provided OUTSIDE of the joint and INTRA-articular means getting an injection INSIDE of the joint.
For instance, an extra-articular injection would likely be provided in the presence of a muscle strain directly to the muscle itself. On the other hand, if you have knee osteoarthritis, an intra-articular injection would be provided in an attempt to reduce your knee pain.
Are they effective?
As usual, it depends. Your condition, individual response to the injection, beliefs, the amount of medicine used, and much more all play a role in the effectiveness of the injection. According to the literature that we’ve reviewed, for most musculoskeletal conditions, these injections can reduce pain and improve function in the SHORT-TERM. However, many studies show there aren’t any other significant benefits and they don’t reduce your LONG-TERM risk of surgery.
Here are a few findings:
A systematic review of spinal pain showed that NSAIDs improved pain and function in the immediate and short-term.⁴
A study showed that NSAIDs and corticosteroids had positive effects on pain, disability, and function in the treatment of tendinopathies in the short-term but reoccurrences were common.⁵
Regarding acute soft-tissue injuries, NSAIDs were effective at reducing pain between 7 – 10 days but had no long-term effect.⁶
Corticosteroids were shown to be effective in the treatment of plantar fascia pain anywhere between 4 – 12 weeks. This positive effect was only achieved 22.9 – 52.8% of the time.⁷
A systematic review of corticosteroids and their effect on lateral epicondylitis showed they had a short-term beneficial effect on pain but a NEGATIVE EFFECT in the intermediate term.⁸
You might ask, “If they can potentially reduce my pain and improve my function in the short term, why wouldn’t I consider getting one?”
The Dark Side…
Over the last few decades, studies have shown the potential for minor to serious complications with these drugs, especially when injected. In addition, despite evidence showing that these forms of treatment might be detrimental to your health, they’re still widely used for many conditions…umm, that’s concerning.
And the research says…
An in vitro study showed corticosteroids used to treat tendon tissue decreased cell viability and collagen synthesis, both of which are vital for tendon health and healing.⁹
NSAID use accounts for 70,000 HOSPITALIZATIONS AND 7,000 DEATHS PER YEAR. The elderly are 7x more likely to experience adverse effects, including bleeding. This same study said that gastrointestinal toxicity can occur in up to 20% of patients on full doses of NSAIDs.¹⁰
52 orthopedic surgeons reported the following complication percentages¹⁰:
Fat Necrosis = 64%
Skin Depigmentation = 67%
Tendon Rupture = 17%
Accelerated Joint Destruction = 17%
Systemic Reactions = 60%
When muscle tissue was injected with NSAIDs, MUSCLE DEGENERATION and infiltration of inflammatory cells were observed up to 7 days after injection.¹¹
A systematic review of extra-articular corticosteroid injections reported complications of skin and perilymphatic atrophy, SOFT-TISSUE CALCIFICATION, skin defects, and Achilles and plantar fascia rupture.¹²
A systematic review of intra-articular corticosteroid injections showed that most medications had a chondrotoxic effect (chondro- meaning cartilage), which leads to the BREAKDOWN of the joint itself.¹³
When treating knee osteoarthritis, intra-articular corticosteroid injections caused greater cartilage loss than when the joint was injected with saline.¹⁴
A study reviewing fluoroscopically guided intra-articular cervical (neck) injections listed the following adverse events¹⁵:
Spinal cord, cerebral, and cerebellar infarction
Cortical blindness
Vertebral artery occlusion
Hippocampal atrophy
Quadriplegia
Brainstem herniation
Paresis of the face and upper limbs
Paraplegia
Grand Mal seizure
Annddd DEATH
The complications from this last study are more a result of the procedure. An intra-articular injection into the neck, which is close to the spinal cord and/or brain stem. These side effects are rare.
I don’t know about you, but the “dark side” sounds pretty risky.
Things to consider
Corticosteroid injections provided to muscle tissue or to a tendon may cause the DETERIORATION of that muscle/tendon or delay the healing process from an injury or surgery.
Corticosteroid injected into the joint may cause the joint to BREAKDOWN at a faster rate.
Gastrointestinal (GI) symptoms with NSAIDs are common, especially in people who already have GI problems.
Injections, regardless of the medication used, may cause adverse side effects in the skin layers such as fat necrosis (death) or even skin atrophy (wasting away).
People with conditions like cardiovascular disease, diabetes, high cholesterol, etc. need to be MORE CAUTIOUS when considering the use of these drugs, regardless of the type of administration.
Severe side effects and complications such as paraplegia or even death, are possible. HOWEVER, they are rare and more unlikely to occur.
Conclusion
These are POTENTIAL side effects and complications. They’re not given. You have to remember, that inherent risks are associated with all treatments, especially invasive treatments like injections.
First and foremost, that doesn’t mean you shouldn’t consider injections as a form of treatment for your condition. This post isn’t meant to scare you. It’s to educate you on the pros and cons of a commonly used treatment so you can make the best decision for yourself
Second, your doctor recommends these treatments for good reasons in the first place. And, as you’ve seen, injections MAY help relieve some of the pain you’re experiencing while also improving your function. This short-term improvement in pain and function might allow you to self-manage or attend physical therapy to improve your condition for the LONG TERM.
The recommendation I give most of my patients is that if you can’t properly rehab your condition, work, or enjoy your hobbies due to pain, you should consider an injection. Once an injection is given, my general rule of thumb is that if you don’t get at least 2 months of considerable relief from pain, then having another injection likely isn’t worth the risks.
More than anything, we hope this blog demonstrated the importance of ASKING QUESTIONS, something we encourage often. You should never be afraid to ask your medical provider, including us, questions. It’s vital to know as much as possible about your condition and the options available to you. This can help you determine risk vs. reward and give you an idea of how you should proceed with your care. Remember, at the end of the day, you get to choose how you are treated.
Resources:
Hill Jr, JJ (1989). Survey on the use of corticosteroid injections by orthopaedists. Contemp. Orthop., 18, 39-45.
