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Steroids May Make Knee Arthritis Worse

If you’re one of the 32 million Americans who suffer from osteoarthritis of the knee, our primary care doctors in Delray Beach want to alert you to a new study that may impact how you’re treated for that condition.

Osteoarthritis of the knee will affect at least half of people in their lifetime and accounts for the majority of the more than 700,000 knee replacements in the U.S. each year.

What is Arthritis?

Arthritis is an informal way of referring to more than 100 types of joint disease, but the two most common forms are osteoarthritis and rheumatoid arthritis.

The typical symptoms associated with arthritis are pain and swelling in the joints, stiffness, and decreased range of motion. Symptoms may come and go and may be mild, moderate, or severe. Symptoms can stay the same for years but may progress or get worse over time.

Osteoarthritis (also known as degenerative arthritis) occurs when the cartilage—the slick, cushioning surface on the ends of the bones—wears away, causing the bone to rub against the bone, and causing pain, swelling, and stiffness. Rheumatoid arthritis is a type of inflammatory arthritis. In other words, it mistakenly attacks the joints with uncontrolled inflammation, potentially causing joint erosion.

Often thought of as an older person’s affliction, in fact, nearly half of adults with osteoarthritis are under age 65. Even more surprising, the rate of osteoarthritis of the knee has doubled since the middle of the 20th Century, according to a study published in the Proceedings of the National Academy of Sciences (PNAS).

Treatment Caution

Unfortunately, there is no cure for arthritis. Depending on its severity, there are numerous ways to treat knee osteoarthritis (KOA).

Severe cases may require surgery, including arthroscopy, and even more drastic measures such as knee or hip replacement. Other approaches to address the pain include platelet-rich plasma (PRP) injections, which are often not covered by insurance, and steroid injections into the site of the pain.

Unfortunately, two new studies, which were presented at last month’s annual meeting of the Radiological Society of North America (RSNA), found that these commonly used steroid injections may be making the condition worse.

One study, by researchers at the University of California in San Francisco, split 210 people with KOA into three groups. Over a two-year period 44 received the standard corticosteroid injections, 26 received injections with hyaluronic acid, a less-common treatment for the condition, and 140 people in the control group did not receive injections.

MRI images taken before and after showed that the KOA in those who received the steroids significantly worsened, but the disease improved in those who received the hyaluronic injections.

Similar Study Results

The second study, from researchers at the Chicago Medical School of Rosalind Franklin University of Medicine and Science, reviewed data for 150 KOA patients, also divided into three groups. Fifty received steroid injections, 50 received hyaluronic acid injections, and 50 received no injections over the four years of the study.

Again, the KOA in those who received the steroid injections had worsened, compared to the other two groups.

Both studies were part of a larger project known as the Osteoarthritis Initiative, involving nearly 5,000 people with KOA.

They also seemed to confirm a 2019 study, which suggested that steroid injections could not only worsen the condition but also accelerate the need for joint replacement surgery.

In that study, researchers at Boston Medical Center reviewed the data on 459 arthritis patients who received corticosteroid injections in the hip or the knee in 2018. They found that eight percent of them developed complications, including cartilage loss, stress fractures, bone deterioration, and destruction of the joint over the two- to 15-month follow-up period.

Cautions and Caveats

Some experts were wary of the findings of all these studies.

Jonathan Samuels, a rheumatologist at NYU Langone Health, told NBC News that it’s difficult to determine causation in studies like these because many factors can influence arthritis progression and no two patients are the same.

“We don’t have the biology to prove that the injection itself is causing accelerated damage,” he said. “It’s hard to connect the dots from injection to damage from this preliminary data. But it’s an important question because it’s such a common practice to be injected with steroids.”

Even the author of the Chicago study, Dr. Upasana Darbandi, acknowledged the possible difference between what the joints look like in imaging studies and what the subjects are feeling.

“You might see that the knee looks bad on a radiograph, but the patient might not be having worse symptoms,” he told CNN.

He also cautioned against people who are experiencing pain avoiding the shots out of fear of longer-term damage.

“Even though [the injections] might progress osteoarthritis, it doesn’t mean there’s no beneficial aspect of it or that they should not be used,” he said, “because they are effective short-term for putting a Band-Aid on the pain.”

Other Treatments

In addition to surgery and injections, here’s how to help manage KOA pain and symptoms:

  • balancing activity with rest to reduce inflammation
  • using hot and cold therapies including warm baths, heating pads, heat wraps, paraffin wax, and ice massages
  • engaging in regular physical activity
  • strengthening the muscles around the joint for added support
  • avoiding excessive repetitive movements
  • taking over-the-counter (OTC) pain relievers or anti-inflammatory medications

Other proven complementary therapies the AF recommends include:

  • acupuncture
  • massage
  • hypnosis
  • biofeedback
  • cognitive behavioral therapy (CBT)
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