Contraindications for Steroid Knee Injections
Intra-articular corticosteroid knee injections are contraindicated in the presence of active joint infection, fracture, prosthetic joint infection, and within 3 months prior to planned knee replacement surgery. 1, 2
Absolute Contraindications
- Active joint infection: Injecting steroids into an infected joint can worsen the infection and lead to septic arthritis 3
- Fracture: Corticosteroids may impair healing and worsen bone health 1
- Planned knee replacement surgery within 3 months: Increased risk of periprosthetic joint infection 2, 4
- Prosthetic joint infection: Steroids can suppress immune response and worsen infection 3
Relative Contraindications
Patient-Specific Factors
- Uncontrolled diabetes mellitus: Patients should be informed about the risk of transient hyperglycemia (particularly days 1-3 post-injection) and advised to monitor glucose levels closely 2
- Severe immunosuppression: Higher risk of infection and delayed healing
- Significant bleeding disorders: While not an absolute contraindication, caution is needed in patients with high bleeding risk 2
Joint-Specific Factors
- Unstable joint: May worsen instability
- Severe joint destruction: Limited benefit and potential for accelerated progression of osteoarthritis 5
- Recent joint trauma: May delay healing
Frequency Limitations
- Overuse of injections: Limit to 3-4 injections per year to avoid potential adverse effects 1
- Recent prior injection: Allow adequate time between injections (typically at least 3 months)
Evidence on Specific Contraindications
Pre-Surgical Timing
The evidence regarding injections before knee replacement surgery is particularly strong. A 2019 study found that both corticosteroid and hyaluronic acid injections given within 3 months before total knee arthroplasty significantly increased the risk of periprosthetic joint infection (odds ratio 1.21 for corticosteroids) 4. The VA/DoD Clinical Practice Guideline specifically recommends avoiding corticosteroid injections for 3 months preceding joint replacement surgery 2.
Long-Term Effects
Recent research suggests that repeated corticosteroid injections may accelerate osteoarthritis progression. A 2020 study found that patients receiving intra-articular corticosteroid injections had a 57% higher risk of requiring knee arthroplasty compared to matched controls who did not receive injections 5.
Infection Risk
While infection is rare, it remains the most serious potential complication. Aseptic technique should always be used when performing intra-articular therapy to minimize this risk 2.
Special Considerations
Diabetic Patients
For patients with diabetes, especially those with suboptimal control, the EULAR recommendations specifically advise informing patients about the risk of transient increased glycemia following intra-articular glucocorticoid injections. These patients should monitor glucose levels particularly from the first to third day after injection 2.
Anticoagulated Patients
According to EULAR recommendations, intra-articular therapy is not contraindicated in people with clotting/bleeding disorders or taking antithrombotic medications, unless bleeding risk is high 2.
Post-Injection Care
- Avoid overuse of injected joints for 24 hours following injection
- Complete immobilization is discouraged 2
- Monitor for post-injection flare, which typically resolves within 24-48 hours
By carefully screening for these contraindications and following appropriate guidelines, the safety and efficacy of intra-articular corticosteroid knee injections can be optimized while minimizing potential risks.