Is a steroid injection in the right knee an appropriate treatment option for this patient with a history of multiple injections and ongoing knee symptoms?

From the Guidelines

A steroid injection in the right knee is not the most appropriate treatment option for this patient at this time, given the patient's significant weight loss and the potential for alternative treatments to be effective. The patient has a history of multiple injections and ongoing knee symptoms, and while corticosteroid injections can provide temporary relief of pain and inflammation, repeated injections may potentially accelerate cartilage damage over time 1.

Considering the patient's significant weight loss, which is a positive development in managing knee osteoarthritis, it would be beneficial to reassess the underlying cause of knee pain and explore other treatment options. The patient's weight loss may have improved their condition, and alternative treatments such as physical therapy, oral anti-inflammatories, or even consideration of surgical interventions should be discussed before proceeding with another injection 1.

Additionally, the American Academy of Orthopaedic Surgeons recommends against the routine use of hyaluronic acid in patients with knee osteoarthritis, and the evidence for platelet-rich plasma injections is inconsistent 1. The patient's history of patellar dislocations and possible MPFL reconstruction surgery should also be taken into account when considering treatment options.

Given the patient's complex medical history and the potential risks and benefits of steroid injections, a more comprehensive approach to managing the patient's knee pain, including reassessment of the underlying cause and exploration of alternative treatments, is warranted. The patient should be advised to continue with weight management and consider physical therapy to improve knee function and reduce pain, and other treatment options should be discussed before proceeding with another injection 1.

From the Research

Patient History and Current Condition

• The patient is a 45-year-old male with a history of right knee pain, stiffness, and instability for 8 years.
• He has tried various treatments, including ibuprofen, acetaminophen, physical therapy, home exercise program, activity modification, bracing, and corticosteroid injections, which have failed to adequately control his symptoms.
• The patient has a history of patellar dislocations and possible MPFL reconstruction surgery.
• He has experienced significant weight loss, potentially 100 lbs, since his last visit.

Treatment Options

• A steroid injection in the right knee is being considered as a treatment option.
• According to 2, intraarticular corticosteroid injections are supported by strong evidence for the management of arthritis, including osteoarthritis, with significant pain relief and functional improvement for months up to 1 year after the injection.
• However, 3 suggests that corticosteroid injections may increase the risk of requiring knee arthroplasty, with a hazard ratio of 1.57 and an absolute risk increase of 9.4% at 9 years' follow-up.
• 4 found that intra-articular corticosteroid injections can be effective in reducing pain and improving function in patients with total knee arthroplasty, but should only be performed after ruling out conditions unlikely to improve with the injection.
• 5 notes that the efficacy of intra-articular corticosteroid injections varies in the published literature, and providers should be aware of the adverse effects and potential complications of these injections.
• 6 provides guidelines for the use and safety of corticosteroid injections in joints and musculoskeletal soft tissue, including recommendations for effective doses and techniques to minimize adverse events.

Considerations for Steroid Injection

• The patient's history of multiple injections and ongoing knee symptoms should be taken into account when considering a steroid injection.
• The potential benefits of a steroid injection, including short-term pain relief and functional improvement, should be weighed against the potential risks, including increased risk of knee arthroplasty and adverse events such as cartilage damage and infection.
• The patient's significant weight loss since his last visit may be a factor in considering a steroid injection, as it may have impacted his knee symptoms and overall health.