Steroid injection reduces knee pain, allowing you to be more active. Wait, what?

Arthritis gets worse as the number of cycles of movement by an affected joint increase. In other words, arthritis + more activity = worse arthritis. In addition, inflammation is also known in other situations as “healing.” In theory, steroid injection could make your knee arthritis worse by making you more active with reduced healing. Hmm. The important news here is that it is not a theory anymore.

A new study from the University of California at San Francisco used magnetic resonance imaging to show that steroid injections relieve knee pain, but they make the MRI (Magnetic Resonance Imaging) findings suggesting underlying arthritis worse. Yikes.

To put this in context, the doctor-recommended treatment for knee pain is 3 weeks of home care followed by an x-ray and physical therapy. Patients with severe arthritis on x-ray who fail 12 weeks (about 3 months) of conservative care need a new knee (total knee replacement); whereas patients with moderate arthritis can often get by with steroid injection for pain control, sometimes followed by an injection of hyaluronic acid to “lubricate” the knee.

Of note, we are talking about people with arthritis, and NOT ACL (anterior cruciate ligament) or meniscal tears here. Soft tissue tears of the meniscus or ACL are shown on MRI and repaired by Orthopedic Surgeons specializing in Sports Medicine using arthroscopic surgery. Whereas severe arthritis is treated by orthopedic surgeons who are fellowship trained in joint replacement.

We have always known that steroids are dirty drugs with legendary side effects. But they worked well to reduce pain! Skeptics have long pointed out that there is no fountain of youth and covering up pain may lead to harm. Once again, if it seems too good to be true, it probably isn’t. But where does that leave people with severe knee pain, but their arthritis is not technically severe enough for total knee replacement?

Hyaluronic acid (AKA Synvisc) is a liquid preparation that has chemical features similar viscosity as synovial fluid normally found in the knee. It makes sense, therefore, that HA injection could lubricate an arthritic knee. Indeed, in the same study that showed MRI changes of arthritis worsen after steroid injection, HA injection on the other hand relieved knee pain, without the bad signs. Doctors do not typically react to a single study— in case there is an error. But a similar work using x-ray instead of MRI this month showed the same thing. Taken together this is convincing evidence that steroid injections in the knee make arthritis worse.

Get HA injections instead.