Would a corticosteroid injection near the joint be effective if an injection directly into the area of active inflammation, as indicated by a bone scan, is unsuccessful?

From the Guidelines

Injecting corticosteroids near a joint showing active inflammation on a bone scan may still be beneficial even if a previous direct injection was ineffective, as suggested by the 2017 ASAS-EULAR management recommendations for axial spondyloarthritis 1. The medication can diffuse through tissues to reach the inflamed area, potentially reducing inflammation and pain. However, the effectiveness depends on several factors including the specific condition, severity of inflammation, and anatomical considerations. If the first injection failed, it's worth discussing with your physician about modifying the approach, such as using image guidance (ultrasound or fluoroscopy) to ensure accurate placement, adjusting the corticosteroid type or dose, or considering alternative treatments like physical therapy or systemic medications. Corticosteroids work by suppressing inflammatory pathways and immune responses, but their effectiveness can vary between patients and conditions. Some key points to consider when deciding on the placement of corticosteroid injections include:

• The proximity to the target area matters, as the concentration of medication decreases with distance from the injection site, potentially limiting therapeutic effects if placed too far from the inflamed area.
• Local injections with glucocorticoids may be an option to treat arthritis and enthesitis, although direct evidence is lacking, as stated in the 2017 ASAS-EULAR recommendations 1.
• Patients with axial disease should not receive long-term treatment with systemic glucocorticoids, according to the same recommendations 1. It is essential to weigh the potential benefits and risks of corticosteroid injections and to consider individual patient factors, such as the underlying condition, medical history, and previous responses to treatment, when making decisions about injection placement and technique.

From the FDA Drug Label

The dose for intra-articular administration depends upon the size of the joint and varies with the severity of the condition in the individual patient. In chronic cases, injections may be repeated at intervals ranging from one to five or more weeks, depending upon the degree of relief obtained from the initial injection Treatment failures are most frequently the result of failure to enter the joint space. Little or no benefit follows injection into surrounding tissue If after long-term therapy the drug is to be stopped, it is recommended that it be withdrawn gradually rather than abruptly.

If the corticosteroid injection doesn’t work when put in the back in the area of active inflammation on a bone scan, it may not help to put corticosteroid close to that joint if the initial injection was properly administered into the joint space.

• The key factor is ensuring the injection is made into the synovial space to obtain the full anti-inflammatory effect.
• Treatment failures are often due to failure to enter the joint space, and injecting into surrounding tissue may not provide any benefit.
• Repeated injections may be necessary in chronic cases, but the effectiveness depends on the individual patient's response and the severity of the condition 2.

From the Research

Corticosteroid Injections for Musculoskeletal Indications

• The use of corticosteroid injections for musculoskeletal indications is a common practice, but it is associated with potential side effects, including local and systemic effects 3.
• Local side effects include postinjection flare, skin hypopigmentation and atrophy, infection, tendon rupture, accelerated progression of osteoarthritis, and osseous injury 3.
• Systemic side effects include adrenal suppression or insufficiency, facial flushing, hypertension, hyperglycemia, and osteoporosis 3, 4.

Efficacy of Corticosteroid Injections

• The efficacy of corticosteroid injections in treating musculoskeletal conditions is well established, but the evidence is limited for certain conditions, such as rotator cuff disease 5.
• Corticosteroid injections have been shown to be effective in treating inflammatory arthritis, osteoarthritis, inflammatory tenosynovitis, and bursitis associated with rheumatic diseases 5.
• However, the use of corticosteroid injections for lateral epicondylosis has been shown to worsen long-term outcomes 5.

Combining Corticosteroid Injections with Other Therapies

• Combining intra-articular corticosteroid injections with anti-TNF agents has been shown to be safe and effective in achieving prolonged remission in patients with recurrent inflammatory monoarthritis 6.
• This combination therapy may be attractive and promising for patients who suffer from recurrent inflammatory monoarthritis or oligoarthritis 6.

Placement of Corticosteroid Injections

• The placement of corticosteroid injections close to the joint may be effective in treating conditions such as osteoarthritis and inflammatory arthritis 5, 6.
• However, the evidence is limited, and further research is needed to determine the optimal placement and dosage of corticosteroid injections for different musculoskeletal conditions 3, 7, 4.