by Jason Schexnayder, PT, DPT, CMTPT

“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 in the medical field. Particularly, we will focus on corticosteroid and NSAID (non-steroidal anti-inflammatory drugs) injections. We will discuss the potential side effects and whether or not they’re effective.

Both types of injections are still 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 oN SAID Injections…

See what we did there?

😑🤦🏼‍♂️

Commonly, corticosteroid and NSAID injections are used to treat musculoskeletal conditions like tendinopathy, ligament sprains, bursitis, osteoarthritis, spinal pain, muscle strains, etc. They are both used for other conditions, HOWEVER, for the purpose of this blog, we’re only going to discuss their use for common musculoskeletal conditions.

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?

Simply put, most NSAIDs work by blocking cyclooxygenase (Cox) from doing its job 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. Basically, both of these medications REDUCE THE INFLAMMATORY RESPONSE that occurs during/after injury, illness, infection, etc.

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 23-YEARS-OLD. Therefore, you can safely assume these numbers have increased. Also, a survey of American football players showed that 1 of 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, your 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 to the muscle suspected to be injured. On the other hand, if you have knee osteoarthritis, then the doctor might provide you with an intra-articular injection in an attempt to reduce your knee pain.

 

Are they effective?

As usual, it depends. Your condition, your individual response to the injection, your 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, most studies showed that there were no effects after these short durations and they didn’t reduce your LONG-TERM risk of surgery. Here are a few of  the findings from our reading:

  • A systematic review on spinal pain showed that NSAIDs improved pain and function in the immediate and short-term4
  • 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 common5
  • In regard to acute soft-tissue injuries, NSAIDs were effective at reducing pain between 7 – 10 days but had no long-term effect6
  • Corticosteroids were shown to be effective in the treatment of plantar fasciitis in regard to pain anywhere from 4 – 12 weeks but only provided this positive effect anywhere from 22.9 – 52.8% of the time7
  • 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-term8

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?”

Inflammation is too often vilified!

As we mentioned, both types of drugs alter your body’s inflammatory response. Despite popular belief, inflammation in the presence of an acute injury is an important part of the healing process. 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 in order to reduce pain and decrease the intensity of the inflammatory response. However, this may also alter the natural healing process and cause longer healing times. In most musculoskeletal conditions, inflammation isn’t the villain and is vital in the path towards appropriate healing.

The Dark Side…

Over the last few decades, there are studies that 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. 

Research Information…

  • 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
  • A study showed that NSAID use accounts for 70,000 HOSPITALIZATIONS AND 7,000 DEATHS PER YEAR and 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 percentages: fat necrosis 64% , skin depigmentation 67%, tendon rupture 17%, accelerated joint destruction 17%, and systemic reactions 60%.10
  • When muscle tissue was injected with NSAIDs, MUSCLE DEGENERATION and infiltration of inflammatory cells, etc., 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 corticosteroids 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 events:  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, Horner’s Syndrome, and more. Some of these complications lead to DEATH as well.15

I don’t know about you, but the “dark side” sounds pretty risky. 

Just to be clear, the complications from the last study listed are more a result of the procedure and not the medication being used.

Things to remember.

  1. 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.
  2. Corticosteroid injected into the joint may cause the joint to BREAK-DOWN at a faster rate.
  3. NSAIDs have a high likelihood of causing gastrointestinal (GI) symptoms, especially in people who already have GI problems.
  4. 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).
  5. 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.
  6. Severe side effects and complications such as paraplegia or even death, are possible, especially depending on how these drugs are injected. HOWEVER, they are rare and more unlikely to occur.

In Conclusion…

These are just some POTENTIAL side effects and complications. You have to remember, there are inherent risks with all drugs and treatments. That’s why drug commercials list more side effects than conditions the drug treats.

First and foremost, that doesn’t mean you shouldn’t consider injections as a form of treatment for your condition. Second, your doctor has good reasons for recommending them 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 do the things you need to (properly prescribed exercise) in order to improve your condition for the LONG-TERM

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. We’re talking about your health and well-being, so it’s vital to know as much as possible about your condition and the options you have 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:

  1. West SG. (1997). Nonsteroidal Anti-Inflammatory Drugs: Rheumatologic Secrets. Philadelphia: Heurley and Belfres Inc; 465–472.
  2. Hill Jr, JJ (1989). Survey on the use of corticosteroid injections by orthopaedists. Contemp. Orthop.18, 39-45.
  3. Tricker R. Painkilling drugs in collegiate athletics: knowledge, attitudes, and use of student athletes. J Drug Educ. 2000;30(3):313-324.
  4. Machado GC, Maher CG, Ferreira PH, Day RO, Pinheiro MB, Ferreira ML. Non-steroidal anti-inflammatory drugs for spinal pain: a systematic review and meta-analysis. Annals of the Rheumatic Diseases. 2017;76(7):1269-1278.
  5. Leadbetter WB. Anti-inflammatory therapy in tendinopathy: the role of nonsteroidal drugs and corticosteroid injections. In: Maffulli N, Renström P, Leadbetter WB, eds. Tendon Injuries: Basic Science and Clinical Medicine. Springer; 2005:211-232.
  6. Ziltener JL, Leal S, Fournier PE. Non-steroidal anti-inflammatory drugs for athletes: An update. Annals of Physical and Rehabilitation Medicine. 2010;53(4):278-288.
  7. Ang TWA. The effectiveness of corticosteroid injection in the treatment of plantar fasciitis. Singapore Med J. 2015;56(8):423-432.
  8. Olaussen M, Holmedal O, Lindbaek M, Brage S, Solvang H. Treating lateral epicondylitis with corticosteroid injections or non-electrotherapeutical physiotherapy: a systematic review. BMJ Open. 2013;3(10):e003564.
  9. Wong M, Tang Y, Fu S, Lee K, Chan K. Triamcinolone suppresses human tenocyte cellular activity and collagen synthesis. Clinical Orthopaedics and Related Research. 2004;421:277-281.
  10. Leadbetter WB. Anti-inflammatory therapy in tendinopathy: the role of nonsteroidal drugs and corticosteroid injections. In: Maffulli N, Renström P, Leadbetter WB, eds. Tendon Injuries: Basic Science and Clinical Medicine. Springer; 2005:211-232.
  11. Reurink G, Goudswaard GJ, Moen MH, Weir A, Verhaar JAN, Tol JL. Myotoxicity of injections for acute muscle injuries: a systematic review. Sports Med. 2014;44(7):943-956.
  12. Brinks A, Koes BW, Volkers AC, Verhaar JA, Bierma-Zeinstra SM. Adverse effects of extra-articular corticosteroid injections: a systematic review. BMC Musculoskelet Disord. 2010;11(1):206.
  13. Wernecke C, Braun HJ, Dragoo JL. The effect of intra-articular corticosteroids on articular cartilage: a systematic review. Orthopaedic Journal of Sports Medicine. 2015;3(5):2325967115581163.
  14. 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.
  15. Engel A, Society SD of the ISI, King W, Society SD of the ISI, MacVicar J, Society SD of the ISI. The effectiveness and risks of fluoroscopically guided cervical transforaminal injections of steroids: a systematic review with comprehensive analysis of the published data. Pain Med. 2014;15(3):386-402.