When are cortisone (corticosteroid) injections helpful for knee issues, particularly in conditions such as osteoarthritis, rheumatoid arthritis, or after a knee injury?

When Cortisone Injections Are Helpful for the Knee

Intra-articular corticosteroid injections are most helpful for acute exacerbations of knee pain, particularly when accompanied by joint effusion (swelling), providing effective short-term pain relief lasting 1-4 weeks. 1

Primary Indications

Knee Osteoarthritis

• Acute flares with effusion are the strongest indication - corticosteroid injections provide clinically meaningful pain reduction (approximately 22% greater than placebo) at 1 week post-injection 1, 2
• Pain relief is statistically significant through 2-3 weeks, with some patients experiencing benefits up to 12 weeks, though effect diminishes substantially after 4 weeks 3, 2
• Not recommended as first-line therapy - should be offered after inadequate response to acetaminophen or NSAIDs 1
• Functional improvement parallels pain reduction during the effective period but is less consistently demonstrated than pain relief 3, 2

Rheumatoid Arthritis

• Indicated for residual active joints (one or few joints) as part of therapy adjustment when systemic disease-modifying drugs are optimized 1
• Can provide short-term improvement while adjusting systemic medications 1

Acute Gout

• Recommended as a first-line option for acute gouty flares affecting the knee, particularly when oral medications are contraindicated 1

Knee Tears with Coexisting Osteoarthritis

• May be considered for meniscal pathology when symptomatic knee osteoarthritis is also present, especially with effusion 4
• Provides 1-4 weeks of pain relief as part of conservative management before considering surgical intervention 4

Clinical Decision Algorithm

Step 1: Confirm appropriate diagnosis and rule out contraindications 1

• Absolute contraindication: within 3 months of planned knee replacement surgery (infection risk) 1, 4
• Rule out septic arthritis - examine joint fluid if present before injecting 5
• Avoid injection into infected sites 5

Step 2: Identify ideal candidates 1, 6

• Presence of joint effusion significantly increases likelihood of benefit
• Acute pain exacerbation rather than chronic stable pain
• Inflammatory component evident (warmth, swelling, restricted motion)

Step 3: Optimize timing and frequency 1

• Maximum frequency: every 3-4 months for the same joint 1, 4
• Decision to reinject should consider benefits from previous injections 1
• If no documented improvement from previous injection, reconsider indication 6

Step 4: Set realistic expectations 3, 2

• Primary benefit window: 1-4 weeks
• Pain relief typically peaks at 1 week
• Benefits diminish substantially by 12-24 weeks
• This is short-term treatment for a chronic problem 2

Important Caveats and Safety Considerations

Patient-Specific Warnings

• Diabetic patients must monitor glucose levels for 1-3 days post-injection due to transient hyperglycemia risk 1, 4
• Patients should avoid overuse of injected joint for 24 hours, but immobilization is discouraged 1, 4
• Aseptic technique is mandatory to prevent septic arthritis 1

When Corticosteroids Are NOT the Answer

• Chronic stable knee pain without effusion - evidence for benefit beyond 4 weeks is lacking 3, 2
• Hand osteoarthritis - generally not recommended (knee is different) 1
• Unstable joints - injection generally not recommended 5

Comparison to Hyaluronic Acid

• Corticosteroids have faster onset (1 week) but shorter duration than hyaluronic acid products 3
• Hyaluronic acid shows superior efficacy between 5-13 weeks post-injection 3
• Consider hyaluronic acid for patients needing more durable relief after inadequate corticosteroid response 1, 4

Corticosteroid Selection

• Triamcinolone hexacetonide appears superior to betamethasone for pain reduction up to 4 weeks (RR 2.00) 3
• Triamcinolone acetonide dosing for knee: 5-15 mg for larger joints, up to 40 mg for larger areas 5
• Long-acting formulations are preferred for knee osteoarthritis 1

Common Pitfalls to Avoid

• Injecting without confirmed diagnosis - intra-articular steroids should not be administered unless appropriate diagnosis is made 1
• Repeated injections without benefit - if previous injection provided no relief, reconsider the diagnosis and treatment approach 1, 6
• Injecting into tendon substance rather than sheath in tenosynovitis cases 5
• Expecting long-term disease modification - these injections provide symptomatic relief only, not structural improvement 3, 2
• Using as monotherapy - should be part of comprehensive management including exercise, weight loss, and other conservative measures 1