What are the contraindications to steroid (corticosteroid) knee injections?

Contraindications to Steroid Knee Injections

Absolute contraindications to intra-articular corticosteroid knee injections include active joint infection, fracture, hypersensitivity to corticosteroid components, and planned joint replacement surgery within 3 months. 1, 2

Absolute Contraindications

• Active infection:

  • Local joint infection or cellulitis
  • Systemic infection
  • Bacteremia
  • Sepsis 3

• Hypersensitivity:

  • Known allergy to any components of the corticosteroid preparation 2

• Planned joint replacement:

  • Surgery scheduled within 3 months
  • Increased risk of periprosthetic joint infection with odds ratio of 1.21 1, 4

• Fracture:

  • Acute fracture in or around the joint 3

• Prosthetic joint:

  • Routine injections into prosthetic joints should be avoided
  • Only considered after strict screening for prosthetic infection by orthopedic surgeons 5

Relative Contraindications

• Uncontrolled diabetes mellitus:

  • Risk of transient hyperglycemia, particularly days 1-3 post-injection
  • Patients should be informed about the need to monitor glucose levels closely 5, 1

• Bleeding disorders:

  • Significant coagulopathy
  • Patients on anticoagulation therapy (though most guidelines now recommend continuing anticoagulation) 5

• Unstable joints:

  • Severely unstable joint where injection may worsen instability 3

• Frequent injections:

  • More than 3-4 injections per year in the same joint
  • Risk of accelerated cartilage volume loss with repeated injections 5, 1

• Adjacent skin conditions:

  • Psoriasis or other skin disorders at the injection site 3

Special Considerations

• Immunocompromised patients:

  • Higher risk of infection
  • Caution in patients with:
    • Hepatitis B carriers (risk of reactivation)
    • Systemic fungal infections
    • History of amebiasis
    • Suspected Strongyloides infestation 2

• Viral infections:

  • Non-immune patients exposed to varicella or measles require special precautions
  • Prophylaxis with VZIG or IG may be indicated 2

• Osteoporosis:

  • Increased risk of bone mineral density loss
  • Consider alternative treatments in patients with severe osteoporosis 1, 3

Timing Considerations

• Pre-surgical timing:

  • Avoid injections within 3 months of planned joint replacement surgery 1
  • Most recent evidence suggests highest risk is within 2-4 weeks before surgery 4
  • Some studies show no increased risk beyond 4 weeks 4, 6

• Frequency limitations:

  • General recommendation is to limit to 3-4 injections per year in the same joint 5, 1
  • Consider longer intervals between injections if possible

Post-Injection Precautions

• Avoid overuse of the injected joint for 24 hours following injection
• Complete immobilization is discouraged
• Monitor for post-injection flare (typically resolves within 24-48 hours) 1
• Diabetic patients should monitor blood glucose levels for 1-3 days post-injection 5

Clinical Decision Algorithm

1. Assess for absolute contraindications:

   • Active infection? → Do not inject
   • Planned surgery within 3 months? → Consider delaying injection
   • Known hypersensitivity? → Do not inject or consider alternative formulation

2. Evaluate relative contraindications:

   • Uncontrolled diabetes? → Optimize glucose control first and advise close monitoring
   • Bleeding disorder? → Use smaller gauge needle and apply pressure after injection
   • Previous injections? → Ensure not exceeding 3-4 injections per year

3. Consider patient-specific factors:

   • Immunocompromised status → Higher vigilance for infection
   • Prosthetic joint → Consult orthopedic surgeon first
   • Osteoporosis → Consider benefit vs. risk of bone mineral density loss

By carefully screening for these contraindications and taking appropriate precautions, the safety of intra-articular corticosteroid knee injections can be maximized while minimizing potential adverse effects.