Steroid shots and arthroscopic surgery have been mainstays in the treatment of pain and inflammation brought on by knee arthritis. Many people try to delay knee replacement as long as possible, especially if they are relatively young. But new research suggests that steroid injections provide little, if any, benefits and may cause harm.
Do Corticosteroid Injections Help or Harm Knee Arthritis?
Last week we reported that nonsteroidal anti-inflammatory drugs like ibuprofen, naproxen or diclofenac may damage cartilage after long-term use. Radiologists monitored nearly 1000 people with osteoarthritis of the knee. After four years, those taking NSAIDs had less cartilage and more inflammation.
This week, radiologists reported that corticosteroid injections speed joint degeneration in people with knee arthritis. In one study, the researchers compared X-rays of 50 people who got corticosteroid shots to 50 controls and 50 people who receive hyaluronic acid injections. After four years, people who had steroid shots had worse arthritis than people in the other two groups.
Another study used MRI scans to monitor arthritis. 44 of the 210 volunteers got corticosteroid injections in their knees. The images revealed that two years after treatment, knees exposed to steroids had more severe cartilage damage than others in the study.
Why Patients Get Steroid Shots and Surgery:
It is estimated that one out of four patients over 50 years of age has knee pain linked to osteoarthritis. Degeneration of cartilage in the knee not only hurts but can curtail activities. It is hard to hike, dance or move around when your knees ache. Knee replacement is usually a last resort. That means that health professionals often offer other options first.
Doctors like to pride themselves on practicing “evidence based medicine.” That means they often reject so-called alternative treatments that remain unproven. But what if standard medical treatments themselves are ineffective or even counterproductive?
Recommendations from Experts:
Many patients turn to nonprofit organizations like the Arthritis Foundation in the hopes of getting sound, objective recommendations. Here is what the Arthritis Foundation states on its website about these treatment strategies:
“Corticosteroid injections: “Injecting corticosteroid compounds directly into affected joints can be useful for decreasing pain in the short term, although the effect tends to wear off after a few weeks. To maintain relief, you may need to have corticosteroid injections in the same joint every few months, or use another treatment.”
Knee Surgery: “When pain is not helped by other treatments, many people find knee surgery an option well worth pursuing…
Arthroscopy is a minimally invasive knee surgery performed by inserting a lighted scope and narrow instruments through small incisions in the skin over the knee. Arthroscopic surgery can be used for the following:
• to remove or repair torn menisci
• to repair a torn cruciate ligament
• to trim torn pieces of joint cartilage
• to remove loose bodies
• to remove an inflamed joint lining (synovectomy).While knee arthroscopy is a procedure that is helpful for many people, there is controversy over the usefulness of some arthroscopic procedures.”
We Offer a Different Perspective:
The Research on Corticosteroid Shots:
Doctors often treat knee arthritis with steroid injections into the joint. Here is a prior study of the effects.
“Effect of Intra-articular Triamcinolone vs Saline on Knee Cartilage Volume and Pain in Patients With Knee Osteoarthritis.” JAMA, May 16, 2017.
Osteoarthritis of the knee is at its core a condition of inflammation.
The researchers writing in JAMA note that:
“Clinical and epidemiological studies found that inflammation is common in the knee joints of people with knee osteoarthritis and associated with progression of cartilage damage. These observations suggest that suppression of inflammatory processes by corticosteroids (already in widespread clinical use for knee osteoarthritis) might reduce progression of knee osteoarthritis.”
The researchers quickly caution, though, that such steroid shots into the knee joint have been associated with “adverse joint outcomes” and “have raised questions about their potential to damage joints.”
That is why these scientists undertook a two-year clinical trial to test the benefits and harms of such treatment. What they found represents a cautionary tale for any health professional who offers steroid shots to patients with knee arthritis.
What They Did:
The investigators recruited 140 patients with painful knee arthritis. Half were given shots of the corticosteroid triamcinolone every three months for two years. The other half received placebo shots of saline [salt water]. Neither the health professionals nor the patients knew who got what.
What They Found:
Contrary to popular belief, the steroid shots did not reduce knee pain any better than saline injections. There was, however, “greater cartilage volume loss.” That is not a good thing.
In their own words, the authors write:
“The use of MRI in this study enabled direct quantitation of cartilage and soft-tissue structures and showed more cartilage loss in the triamcinolone group than in the saline group.”
In other words, steroid injections provided no noticeable benefit and a certain amount of risk.
Their conclusions:
“These findings do not support this treatment for patients with symptomatic knee osteoarthritis.”
Arthroscopic Surgery for Knee Arthritis:
An arthroscope is a instrument with a tiny camera at the end. An orthopedic surgeon inserts this device into the knee. It allows the doctor to see problems like a torn meniscus or pieces of cartilage that have come loose inside the knee. Very small instruments can then repair tears or remove torn cartilage. However, guidelines from a group of international experts are not encouraging when it comes to arthroscopic knee surgery (BMJ, May 10, 2017).
According to experts writing in the BMJ (May 10, 2017), arthroscopic knee surgery “costs more than $3 billion per year in the U.S. alone.” Are people getting their money’s worth?
The panel of experts who wrote the guidelines analyzed data from 13 randomized trials and 12 observational studies. They were particularly interested in “pain, function and quality of life.”
What They Found:
“The panel is confident that arthroscopic knee surgery does not, on average, result in an improvement in long term pain or function. Most patients will experience an important improvement in pain and function without arthroscopy.”
The lead author and chair of the guideline panel, Reed Siemieniuk, MD, told Reuters Health:
“It does more harm than good. Most patients experience improvement after arthroscopy, but in many cases, this is probably wrongly attributed to the surgery itself rather than to the natural course of the disease, a placebo effect, or (other) interventions like painkillers and exercise.”
Complications can include pain, swelling, infection or blood clot formation.
Dr. Siemieniuk went on to tell Reuters:
“We believe that no one or almost no one would want this surgery if they understood the evidence.”
What Can People with Knee Arthritis Do?
Millions of people suffer from knee arthritis. Just walking can be painful. Jogging, playing tennis or golf may be out of the question. Short of knee replacement surgery, there are not a lot of medical options.
Over the last several years we have learned about serious or even deadly side effects from NSAIDs (non steroidal anti-inflammatory drugs). Celecoxib, diclofenac, ibuprofen, meloxicam and naproxen have been linked to a surprisingly long list of worrisome adverse reactions. They include:
- Stomach ulcers
- Heart attacks
- Strokes
- Atrial fibrillation
- Heart failure
- Hypertension
- Kidney damage
- Liver damage
Learn more about the benefits and risks of NSAIDs at this link:
Now we learn that corticosteroid injections into the knee joint may damage cartilage and produce little, if any, benefit. And surgery for knee arthritis offers modest, if any, help.
Topical NSAIDs vs Oral NSAIDs:
There is some reason to believe that topical NSAIDs may be less troublesome than oral medicines. You can read more about this approach at this link:
Non-Drug Alternatives for Knee Arthritis:
Many physicians pooh-pooh non-drug approaches in general. They bemoan the lack of evidence. That, despite data now demonstrating that traditional medical practices for knee arthritis are either ineffective or harmful.
If you would like to learn more about a range of options you might find our interview with arthritis specialist, Beth Jonas, MD, enlightening. She is open minded and offers a number of practical suggestions. You can listen for free at this link:
In addition, we have prepared a 54-page online resource titled “Alternatives for Arthritis.” In it we discuss in greater detail topical NSAIDs as well as several home remedies:
- Tart Cherries
- The Gin-Raisin Remedy
- Certo and Grape Juice
- Knox Gelatin
- Vinegar and Juice
- Pineapple (bromelain)
Plus, herbs and spices like Ashwagandha, boswelia, turmeric, ginger and stinging nettle.
You will also learn about apitherapy and acupuncture.
Share your own experience with knee arthritis below in the comment section. If you found this information helpful, please vote at the top of the article.
