A new University of California study finds cortisone injections are associated with progression of osteoarthritis in the knee. So where does that leave us? Jim Newman explains.
The latest meeting of the Radiological Society of North America has put the cat among the pigeons in a range of ways. First we had the study about the effects of ibuprofen. Then, the meeting shared results of two studies which both appeared to show that cortisone, a steroid regularly used to reduce osteoarthritic knee pain, was also associated with progression of the disease (that is, whilst it relieves pain in the short term it makes things worse in the long term).
We don’t know (and the study didn’t attempt to explore) exactly why this is the case. It may be that, once they have the pain relief of cortisone coursing through their system, patients feel able to be much more active and therefore do greater damage to their knee. What is clear, however, is that knee surgeons need to be more selective about who we give cortisone injections to as a treatment for arthritis.
The balance to be struck is between alleviating pain and managing the progression of arthritis. So how, as clinicians, should we reach that balance?
When are cortisone injections appropriate?
Patient one has got early-to-moderate arthritis. They’ve been managing pretty well up to now with over-the-counter painkillers and physiotherapy, but then they suffer a major flare up. Their knee balloons with fluid to the extent that they can no longer do their physiotherapy. Without physiotherapy they risk muscle wastage which in turn increases pain. Eventually, the only solution will be a knee replacement and, in this example, that will be required sooner rather than later unless they have a cortisone injection.
Cortisone could help them over that ‘inflammatory hump’. Combined with physiotherapy it could help them return to a position where they are able to manage their osteoarthritis and delay the need for knee replacement. In such circumstances, I’d argue that cortisone is an entirely reasonable option. The same would be true for someone who just needed a temporary burst of pain free mobility, perhaps because they wanted to be able to walk their daughter down the aisle at their wedding.
Patient two has advanced osteoarthritis but is otherwise fit and healthy. They need a knee replacement now. Giving them a steroid injection gives them pain relief for three months, but it doesn’t alter the overall position: they need a knee replacement and they’ll need it even more in three months. In this situation, a knee replacement, not another cortisone injection, is the right course of action.
This research tells us that, as knee surgeons, we need to adjust our criteria for offering cortisone. I have patients for whom cortisone has been an extremely valuable tool in managing their osteoarthritis, but we shouldn’t fall into the trap of assuming it’s appropriate for everyone.
Is hyaluronic acid a better option than cortisone?
One of the studies also compared the progression of osteoarthritis in patients who had cortisone injections with patients who received hyaluronic acid. According to the study, hyaluronic acid patients didn’t show the same progression in their arthritis. To which I might add, “No, but hyaluronic acid didn’t make their knee better either.”
NICE (the National Institute for Health and Care Excellence) has found very little evidence to support the use of hyaluronic acid as a tool for alleviating the symptoms of osteoarthritis. There is good evidence to support the use of cortisone, even if surgeons clearly need to adjust the way they use it.
In search of the Holy Grail
This study, like so many that have gone before it, reflects society’s desperation to find a miracle ‘cure’ for osteoarthritis. Cortisone isn’t a cure. Hyaluronic acid definitely isn’t a cure. And nor are any of the other injectables currently making headlines. Even a knee replacement doesn’t ‘cure’ osteoarthritis any more than a mechanic can cure the worn mechanical parts of your car. They simply replace the worn parts to remove the problem, which is effectively what knee surgeons do.
> Find out more about Jim Newman
> Does Ibuprofen make osteoarthritis knee pain worse?
> Discover more about osteoarthritis, symptoms & treatments
> Discover more about partial or total knee replacements
What Is Osteoarthritis?
What does osteoarthritis look like? What are the symptoms? And short of surgery, how do you treat it?
Visit The Knowledge Hub
Helpful information about knee conditions, injuries, treatments & recovery