Can cortisone injections cause damage to the knee?

Potential Risks of Cortisone Injections to the Knee

While intra-articular corticosteroid injections are strongly recommended for knee osteoarthritis, they may contribute to cartilage loss with repeated use, though the clinical significance of this finding remains uncertain. 1

Benefits vs. Risks of Cortisone Knee Injections

Established Benefits

• Provide short-term pain relief and improved function in knee osteoarthritis 1
• Effects typically last 4-24 weeks depending on the preparation used 1
• Strongly recommended by major guidelines for knee osteoarthritis management 1

Potential Risks

Local Complications

• Cartilage loss with repeated injections 1, 2
• Post-injection flare (temporary pain increase) 3, 2
• Joint infection (rare but serious - estimated at 1 in 3,000 injections) 4
• Accelerated progression of osteoarthritis with frequent use 2
• Increased risk of requiring knee arthroplasty 5, 6
  • Each injection may increase absolute risk of arthroplasty by 9.4% at nine years 5
  • Dose-dependent risk: three or more injections associated with 3.22 times higher odds of requiring total knee arthroplasty 6

Systemic Complications

• Transient hyperglycemia in diabetic patients 1, 7
• Potential adrenal suppression 8, 3
• Facial flushing and hypertension (uncommon) 2

Risk Mitigation Strategies

1. Limit frequency of injections

   • Guidelines suggest avoiding more than 3-4 injections in the same joint per year 1
   • Consider longer intervals between injections

2. Timing considerations

   • Avoid injections within 3 months prior to planned knee replacement surgery 1, 7
   • Rest the injected joint for 24 hours following injection 1, 7

3. Patient selection

   • Use caution in patients with diabetes - monitor glucose levels for 1-3 days post-injection 1, 7
   • Consider alternative treatments in patients at high risk for joint replacement

Clinical Decision-Making Algorithm

1. First-line approach

   • Start with non-pharmacological interventions (exercise, weight management)
   • Consider oral NSAIDs if not contraindicated 1

2. When to consider cortisone injection

   • Persistent pain despite first-line treatments
   • Acute flare of knee osteoarthritis pain 1
   • When NSAIDs are contraindicated or poorly tolerated

3. After injection

   • Monitor response
   • If beneficial, consider repeating no more than 3-4 times per year
   • If minimal benefit, consider alternative treatments

Important Caveats

• The clinical significance of cartilage loss seen on imaging remains uncertain, as it has not consistently correlated with worsening pain or function 1
• Recent research suggests a conservative approach to cortisone injections may be warranted, particularly in patients at risk for knee replacement 5, 6
• Long-term studies on the safety of repeated injections show mixed results 9, 6

In summary, cortisone injections remain an important treatment option for knee osteoarthritis but should be used judiciously with awareness of potential risks, particularly with repeated use over time.