On a daily basis, the few questions I get asked more often than “How old are you?” or “How long have you been doing this?” are, “Should I get a steroid injection?” or more frequently, “Why did the steroid injections not help with my ____ pain?” The utilization of corticosteroid injections for musculoskeletal pain management dates back to the 1950s, but recent research reveals that negative effects to surrounding tissues outweigh the trivial benefits. In the clinic, most people are aware of this pain management option and many have first hand experience. However, it is less common that consumers understand how injections work, adverse effects associated with injections, and more importantly, what is efficient at resolving their pain. The goal of this entry is to provide current research to equip health consumers with the knowledge necessary to make confident, informed decisions about their treatment options.
In the literature, steroid injections are documented to treat a broad array of painful conditions: joint pain associated with arthritis, soft tissue pain (muscles, bursas, tendons, and ligaments), and nerve pain like carpal tunnel syndrome (Brinks et al. 2010). Injections are used for a large range of conditions because they serve one purpose: to attempt short term pain reduction via anti-inflammatory processes and immunosuppressive properties at the cellular level (Pekarek et al. 2011). In other words, injections temporarily halt inflammation, which is the first phase of normal tissue healing similar to how band-aids reduce bleeding. Unfortunately, injections do not address the cause or reasons for re-occurring inflammation. Patients typically notice a greater pain reduction, if any, with an initial injection followed by diminishing returns with subsequent encounters. Literature shows that injections have little or no effect on mitigating pain in chronic conditions. This often leads to frustration because injections are frequently administered after a condition has already become chronic (symptoms for 3 months or longer). Unlike band-aids, injections stimulate tissue breakdown with the gamble of having no effect on pain, or even worse, increased pain or sooner surgical procedure. Therefore, corticosteroid injections should only be cautiously considered for pain control during acute conditions (Mittal et al. 2018).
Injections actually cause further damage to the very tissues they are expected to treat. Specifically, a systematic review identified adverse events of extra-articular (outside the joint) corticosteroid injections ranging from minor to fatal infections, numerous tendon ruptures, and local skin and fat pad atrophy (Brinks et al. 2010). A single injection directly into a ligament results in reduced tensile strength for up to a year post injection (Pekarek et al. 2011). Similar findings are evident in cartilage tissue with intra-articular (inside joint) injections. A recent study compared intra-articular corticosteroid injections versus a placebo solution in 140 patients suffering from knee osteoarthritis over 2 years. This study examined the effects on pain and cartilage health measured by MRI. The results were alarming. No significant difference in knee pain ratings between the groups were identified and the corticosteroid group had significantly greater cartilage loss – a sign of progressing osteoarthritis and the very reason people seek injections (Mittal et al 2018). Corticosteroid injections made these patients worse! Clinically, I find that patients get injections to avoid pain and/or surgery, despite the evidence stating the exact opposite.
There needs to be a paradigm shift. Corticosteroid injections should never be a first line of defense to pain and certainly not a “lets just see if it helps” option. There are numerous studies illustrating that exercise alone is superior to injections. Many even prove exercise alone to be equal, if not better, than injections combined with exercise for managing musculoskeletal pain. So why are steroid injection still commonly used for pain management? A meta-analysis by Mohamadi et al. proposed, “their wide use may be attributable to habit, under-appreciation of the placebo effect, incentive to satisfy rather than discuss a patient’s drive toward physical intervention, or for remuneration, rather than their utility (2016).”
Musculoskeletal pain that gradually develops is associated with poor, repetitive movement patterns that apply abnormal stress to muscle, tendon, ligament and cartilage tissues. This is the root cause of reoccurring inflammation and pain. Just as band-aides would never heal a scrape if the scab were repetitively scratched off, injections will not heal tissues in the body if the faulty movement pattern is not corrected. Don’t expect an injection to heal a movement impairment. Stop insulting your tissues, learn to move efficiently, and let the tissues heal.
Here at Austin Manual Therapy Associates, we specialize in soft tissue/joint mobility, specific exercise for tissue healing, and restore efficient movement patterns for a lifetime of reduced pain. If you or someone you know is struggling with pain, work with one of our experienced physical therapist to stop the tissue bleeding and get you moving in the right direction.