Corticosteroid injections in musculoskeletal care – what physios need to know

Corticosteroid injections (CSIs) are commonly used in the management of musculoskeletal pain, but their widespread use doesn’t mean they’re always being used appropriately. As physiotherapists, we often encounter patients dealing with persistent pain who wonder if a CSI could benefit them. Staying up to date with the latest research and recommendations is crucial for us to fully understand the role, limitations, and benefits of CSIs in various musculoskeletal conditions, so we can help our patients make informed decisions. Nick Livadas’ Masterclass on injection therapy provides a comprehensive overview of CSIs for different conditions. This blog highlights a few key takeaways:

If you’d like an in-depth understanding of the current recommendations on CSIs for a range of musculoskeletal disorders, watch Nick Livadas’ full Masterclass HERE.

Risks and benefits

Interestingly, Nick notes that most of the negative side effects of corticosteroids are associated with long-term oral use rather than local injections. However, this doesn’t mean there are no side effects to using CSIs. Local side effects can include:

• Joint arthropathy
• Tendon weakening
• Post-injection flare (one in five patients)
• Local bleeding/bruising
• Skin depigmentation
• Local infection
• Fat atrophy

Some important systemic effects can include:

• Impaired diabetic control
• Menstrual irregularity
• Immunosuppression
• Anaphylaxis
• Increased systolic blood pressure

As physiotherapists, our primary concern is the risk to the integrity of musculoskeletal structures, particularly bone, cartilage, and tendons. One systematic review found that CSIs can lead to changes in tendon collagen, including collagen necrosis and reduced synthesis, potentially increasing the risk of tendon rupture (1). As for cartilage, it’s been found that high doses may lead to chondrocyte apoptosis and reduced collagen synthesis (2).

Despite these risks and the seemingly short-lived benefits, various clinical guidelines still support the use of CSIs as an adjunct therapy. Injection therapy remains a contentious topic in healthcare research; watch Nick explain the limitations in CSI research in the below video from his Masterclass:

CSIs for knee pain

One of the most common areas for CSI use is the knee, particularly for knee osteoarthritis. The National Institute for Health and Care Excellence (NICE) guidelines (3) recommend that clinicians only consider CSIs when other pharmacological treatments are ineffective or unsuitable, or to support therapeutic exercise. It’s also essential to inform patients that the effect is short-term (2-10 weeks). See Nick explain the guidelines in the below snippet from his Masterclass:

While guidelines support the use of CSIs in some situations, it’s important to understand the potential risks associated with repeated use. One trial found that CSIs administered every three months for two years led to significant cartilage volume loss without reducing knee pain in people with knee osteoarthritis (4). An additional study found that repeated CSIs could accelerate osteoarthritis progression, and cause rapid joint destruction, bone loss and subchondral insufficiency fractures (5). For those using CSIs to create a “window of opportunity” for exercise, one study found that a CSI in a painful knee two weeks before starting an exercise program did not produce any additional benefits when compared to controls (6). Moreover, intra-articular CSIs within three months before total knee arthroplasty may significantly increase the risk of prosthetic joint infection (7). Currently, evidence supports CSI use only if administered more than six months before surgery.

This is not to say “no” to using CSIs for knee osteoarthritis – but these are factors to keep in mind and educate your patient about. It’s especially important to emphasise that potential benefits are short-term only, as well as the risks associated with repeated use.

CSIs for the shoulder

Another common area for CSI use is the shoulder. A familiar scenario may be those patients diagnosed with “bursitis” and told that a CSI may be indicated. For those dealing with significant and persistent pain hindering their quality of life, a CSI may seem like a tempting quick fix. Others may have heard from friends or acquaintances about how a CSI magically resolved their shoulder pain. In these situations, it’s essential to have up-to-date information to educate and set realistic expectations for your patients.

A meta-analysis found that for people with subacromial pain, there was no difference between CSI and controls at three months, and about one in five patients experienced a small, transient relief in their pain (8). For some, this might be worth it, just to have some relief. However, arming your patients with knowledge of the risks and benefits is the best way to help them make the right decision for themselves.

Wrapping up

It’s crucial to have honest conversations with our patients about the benefits and limitations of CSIs. While these injections can provide meaningful short-term relief to some, they should be viewed as one tool in a comprehensive treatment plan, not a standalone solution. Educating patients on the importance of long-term management strategies, such as strength training, stretching, and lifestyle modifications, will help them achieve better outcomes in the long run.

In summary, CSIs are most effective when used judiciously and in conjunction with other, more sustainable management strategies. By understanding their role and educating our patients, we can help them navigate their treatment options and work toward lasting relief and improved function.

To gain a deeper understanding of the use of CSIs in a range of different musculoskeletal conditions, make sure you watch Nick Livadas’ full Masterclass HERE.