Non-operative treatment for osteoarthritis includes activity modification (do less, reduce impact, reduce load, reduce distance, etc), topical medications, oral medications, bracing, and injections.
A common injection used in orthopedic clinics many times each day is generically referred to as "cortisone." It is a combination of a local anesthetic (like the dentist uses) and a steroid. There are a variety of local anesthetic agents used (lidocaine, bupivacaine, etc.), and a variety of concentrations available. Additionally, there are a variety of steroids that can be used. Each surgeon likely has a preferred combination.
Just a side-note: the steroids orthopedic surgeons inject for anti-inflammatory purposes are completely different from the anabolic steroids associated with body-building. They will not make you grow muscle.
Although not everybody responds the same, a cortisone injection often provides rapid and significant relief from arthritis pain. This relief can last for months. When the pain returns, we have a discussion regarding the amount and duration of relief experienced. I generally allow my patients to undergo up to 3 cortisone injections per joint, per year.
Some patients aggressively pursue these injections and would accept them much more frequently than I recommend. Others prefer to avoid them entirely. Reasons for this vary. Some patients are simply afraid of the needle. This is a shame, because most patients report only mild discomfort when I've performed a cortisone injection. Other patients are more concerned about the potential detrimental effects. They've heard that cortisone destroys cartilage and will hasten their joint deterioration.
Some in vitro (test tube) and animal studies have shown chondrocyte (cartilage cell) toxicity due to local anesthetics, steroids, and combinations of both. Cartilage cell damage in a test tube does not necessarily mean that an injection into a living human's joint will create similar damage. In fact, another study in which samples of living cartilage were taken after the knee was injected with local anesthetic showed no such effect. While I certainly understand that cells in culture may be negatively effected, I have seen no clinical evidence of joint destruction due to cortisone.
I think it is reasonable to assume, like with most medications, that while there is a benefit, there is also some potential for harm. The key is to use cortisone, like all medications, judiciously. That is, only when indicated, not too often, and at the lowest effective dose.
It is important to remember that we are using cortisone in joints that are already moderately to severely damaged due to arthritis. The joint is already irreversibly damaged due to the cumulative effects of gravity, activity, and time. A cortisone injection can provide a significant improvement in quality of life and can potentially delay surgery. A recent article in the Journal of the American Academy of Orthopedic Surgeons confirms the efficacy of cortisone injections to provide pain relief for osteoarthritis.
Remember, a total joint replacement involves removing ALL of the cartilage from the joint. I would argue that that is much more toxic to the cartilage than a few cortisone injections.
I am not suggesting people should not have their joints replaced when they wear out. The majority of my practice involves replacing destroyed knees, hips, and shoulders. These operations predictably alleviate pain and restore function. Total knee, total hip, and total shoulder replacements, help hundreds of thousands of patients every year in the U.S.
I am suggesting that appropriate use of cortisone can allow some patients to delay an operation, sometimes for years. And if there is a risk that microscopic cartilage damage occurs, the ability to reduce pain and delay surgery is worth it.
Eileen Holdridge(Barb Holdens sister)
6/4/2016 02:38:12 pm
I read what you wrote about cortisone shots for the knee and found it interesting to know...Did not know shots should be be limited to 3 shots per year.I have only had this procedure done 2x over a long period of time ..Just here to say your postings are most interesting..
6/4/2016 03:03:54 pm
Cortisone, like all medication should be appropriately managed. Glad you are enjoying the blog!
11/7/2021 08:52:20 pm
My doctor gives these to me every 4-6 weeks. Been doing that for 3 years. The only real big issue with it is I get really bad cortisone flares.
12/16/2021 04:11:58 pm
This is more frequent that I feel comfortable with, however if it is working for you, this is between you and your surgeon.
11/10/2021 02:47:55 pm
Some areas say 3 months between injections. (4 per year)
Heather R Overton
10/9/2022 10:38:23 pm
I am 43 years old. I went to the Ortho because of knee pain, stiffness, and my knees ached at the end of the day for years.. I have received two steroid injections this far. I was told to young for knee replacement. They did X-rays and I'm in the moderate degenerative stage with arthritis in both knees. I work 8 hours a day as a teacher with young children. I went to my last appointment to discuss surgery and they basically want to do injections every 6 weeks. They don't help for about 2 weeks at a time and I have to pay 140 every time I go in their office to get the shots. I have 6 dependent children in the home. I can't afford that every 6 weeks. I need a permanent solution. I know that knee replacements only last 15-20 years. I've done my research. But I have kids I need to get raised right now and I have to work. I'm not going to be climbing Mount Everest at the end of the day. I just want to get through my work day and go enjoy my kids football games. I live in WV and I need to go to an ortho that will listen to me and do the surgery within the next couple of years.
10/23/2022 09:53:17 pm
While age is a factor in the decision to proceed with knee replacement surgery, it is not the only factor. If your knee arthritis is bothering you so much that you are requiring cortisone injections every 6 weeks, this does not seem sustainable. Perhaps you could try a hyaluronic acid injection. If this does not work, it seems reasonable to consider proceeding with knee replacement surgery, even at your young age. Modern knee replacements should last for at least 20 years (hopefully longer) and revision systems allow reconstruction when the primary replacement eventually does wear out. Sometimes quality of life now must over-ride other, longer-term issues. This is a personal discussion I would encourage you to have with your surgeon.
Teri Woolney (John Stenslands Sister in law)
8/8/2016 11:27:52 am
8/8/2016 12:33:17 pm
I hope you are pleased with the results. My recommendation is to repeat them only if they are very helpful and last for a reasonable period of time. Usually this means no more than 3 per year, per joint.
4/18/2018 12:43:54 am
My surgeon wants to do cortisone in my knee replacement for chronic swelling I do not see where that would help. Have you heard of this and if so what should I worry about if I allow this I had 17 shots in 18 month's in my two knees up till I had replacement my Dr didn't tell me I could only have 3
4/23/2018 10:18:59 pm
9/16/2016 12:05:32 am
Had 1 cortisone shot which has done significant damage to my foot about a year ago. Will my foot eventually heal? It's quite painful. The area seems to have withered and it feels like it's burning and the skin is very tender. Or, will it continue to get worse?
Christopher Gorczynski, MD
9/16/2016 09:54:32 am
We try to avoid steroid injections into soft tissues whenever possible, and when doing so as a last resort, we keep the dose as low as possible. This is because steroids can cause skin discoloration and soft tissue atrophy. This is not seen when injecting into a joint. Unfortunately I am unable to definitively state that this has happened in your case and thus I can not make prognostic statements. I recommend you speak with your orthopedic surgeon. As always, I am happy to offer a second opinion in person if you live near my office. A less good alternative would be a video conference that could be arranged if you wish.
7/11/2018 10:30:47 pm
Dear Dr. Chris, I hurt my right foot in ankle area doing mega hikes....been in boot, xray and mri show nothing. Saw to ortho doctors. One gave cortisone 4-6 inches up leg. Flare. No relief. Second ortho doctor gave in front of ankle [spot where pain]...no help. Started acupuncture. Helped swelling a lot, but still pain. Two months later I've lost pigment in area and tiny spider veins appeared. Today I saw podiatrist, as I've exhausted other possibilities in my knowledge bank. He thinks it could be mechanical so will try an insert to cause my foot to be in different position. One question I have for you, is this: the damage to the tissue and atrophy and loss of pigment...will this heal in time? I want to get back hiking...its what I live to do, its my livelihood as well. Any suggestions?
7/11/2018 11:06:44 pm
8/23/2021 07:10:22 pm
What is your opinion about SI joint injection... I took steroid inject into my SI joint after having pain and stiffness for years in hips groin pelvic and hamstring abs and lower back... Do you think SI joint can be inflamed without arthritis.
9/1/2021 03:37:07 am
@Ayman An occasional SI joint injection can be useful for diagnostic and hopefully therapeutic purposes. And yes, it is possible to experience SI joint pain without arthritis.
5/15/2017 10:52:45 am
I've received so many injections to where my tissue and muscles deteriorated, so went to a different pain management doctor he turned around and gave me another injection. He wants to get MRI W/O CONTRAST and I feel there's other issues that a MRI W/CONTRAST SHOULD BE DONE I STILL SUFFER WITH CONSTANT PAIN I'VE HAD LOTS OF PHYSICAL THERAPY EVEN WATER THERAPY AND CONSTANTLY BEING RECOMMEND TO DO THERAPY DOCTOR'S ARE NOT LISTENING AND PISSING ME OFF. IS THERE A PHYSICIAN HERE IN ST LOUIS THAT YOU COULD RECOMMEND ME TO I WANTING AND NEEDING TO GET TO THE CORE OF THE PROBLEM
5/15/2017 10:43:46 pm
I am sorry to hear of your difficulties. Unfortunately, there is not enough information in your comment for me to provide much guidance. I would suggest that repeating cortisone injections that do not improve symptoms over and over doesn't make much sense to me. Pain can be due to many problems including infection, degeneration, arthritis, trauma, nerve impingement, etc. Without a diagnosis, I can not direct you to a specific physician or recommend a particular treatment. Beyond this, I do not personally know any physicians in the St. Louis area. I would suggest speaking with your primary care physician for a recommendation. If you are ever out in New York I would be happy to provide an opinion in person. It is also possible for us to arrange a phone or video consultation to provide guidance.
2/3/2018 02:39:26 pm
I read your website and felt I need to share - I had an MRI done of my left knee in 2015 and the medial meniscus was there. An injection was done at that time along with removing 45CC of fluid. One or both provided relief. Possible could have been the removal of the fluid which was done at same visit. The reason I say this is that I didn't need anything else for 2 yrs. Then in May 2017, I went back to the Ortho doc for knee pain that started abruptly after sitting /leaning forward for several hours. Without any further diagnostics the doc gave me a 2nd injection. This time it didn't do much at all and when my knee was X-rayed in July 2017, the medial meniscus was MISSING altogether. I've read other sources that assert that the injection can "dissolve" the meniscus. This either from a reaction to the stabilizer for the eprinephrine or that if the epidural sack is missed and the chemical goes directly into the meniscus. It turned out that pain/swelling in 2015 was actually due to knealing on my knees for an extended period of time and the pain in 2017 to present is actually referring from a "shifted vertibrate". An EP Injection in my spiinal area, calmed it down for a time. It was a different Ortho doc that my primary sent me to for 2nd opinion that recognized it.
2/5/2018 08:35:38 pm
4/6/2018 08:07:49 pm
Sounds like you may have what I had. FAI inpingment but it only shows up with contrasting dye
7/2/2017 11:57:31 pm
I am glad to have found this blog. I had a lot of lower back pain for years. Knee pain and ankle pain as well (even when I wasn't overweight), now I had a slip and fall in 2010 and in late 2011 happen to be seen at a chiropractor who stated I had some cervical spine issues that needed a lot of work to prevent further curving etc. it was about an $11,000 quote which I didn't see any real need to pursue since I didn't have a great experience with chiro in general. Fast forward and I have had lots of neck pain and upper back and shoulder issues for the last 6 months. I did rounds of PT, dry needling, all that didn't help and I had a dorsocervical fat pad which was rapidly growing to the point my pain management specialist sent me for an MRI because of the pain and swelling, I couldn't obtain full ROM. MRI came back with the following results:
12/20/2017 11:03:10 pm
I apologize for the delayed response to your question. Assuming you proceeded with epidural steroid injection, I hope you continue to experience relief. This procedure seems reasonable to consider in light of the history and MRI report you provided. Injections like this can be helpful for both diagnostic and therapeutic purposes. This means hopefully they will make you feel better, but if the response is excellent, but only temporary, they also indicate that surgery would likely be worth considering.
12/20/2017 06:42:43 pm
12/20/2017 10:54:53 pm
It sounds like you might have been taking steroids for Crohn's disease? If this is correct, this is quite different from getting an intra-articular injection of cortisone (injection into a joint) for treatment of arthritis.
2/4/2018 03:07:00 pm
Good day. My question is why do they remove your knee fluid prior to a HA injection? My thinking here is once they remove your natural fluid, then it will never come back. That just doesn't sound logical to me. I have heard really good things about the HA injection, but I need some clarity, please. Thank you very much. Also, why can the HA injection only be done one time?
2/4/2018 05:11:01 pm
The synovial fluid in arthritic knees becomes relatively deficient in hyaluronic acid. Hyaluronic acid is a lubricant. Thus, supplementing hyaluronic acid makes sense. If your knee has a very large effusion (is very swollen) this excess, hyaluronic acid deficient synovial fluid, could be removed. It is not routine, however, to remove all the synovial fluid prior to supplementing with hyaluronic acid.
3/16/2018 01:09:18 pm
I woke up one day with a pain in my knee. I am 45 years old and had never had any knee injury. The knee got swollen in a week. After three weeks of swelling and feeling very heavy in my knee and not being able to walk well, I received a Cortisone injection in the knee this past Monday. My knee felt better for a couple of days, but then suddenly yesterday it felt liked it slipped/gave in. It was very painful and it's been painful to walk. The slipping in the knee repeated last night and again this morning. When it slips it's very painful and It's been painful to walk. The knee was not slipping before the cortisone injection. I am very concerned. I would appreciate your opinion on what's going with my knee, why it's slipping and what it is.
3/16/2018 01:18:01 pm
Without additional information, your history suggests you most likely have a torn meniscus. The slipping sensation you are experiencing suggests this could be an unstable tear. This means the meniscus (which is a "C-shaped" shock absorbing cartilage) could be flipping around. In addition to being unpleasant, it could be causing additional damage within your knee. I suggest you see your orthopedic surgeon as soon as you can. You should have an MRI scan to confirm this diagnosis. A symptomatic, unstable meniscal tear, within an otherwise normal knee, should be treated with arthroscopic surgery. This is a very predictable procedure with excellent chance of full recovery.
4/3/2018 05:23:30 pm
Thank you so much for this article. Although the heading is not what i was seeking the article answers much of what i was asking. I do wonder why a GP and an orthopaedic surgeon couldnt have provided the clear explanation you offer.
4/3/2018 07:38:59 pm
An occasional injection for greater trochanteric bursitis is fine. I would not generally recommend a pre-planned series of injections, because how do we know the first injection wouldn't last for many months?
9/15/2018 07:25:35 pm
I just had x-ray and have osteoarthritis of the hips. My situation is odd as I have very good joint space (indication of cartilage) but a lot of bone spurs and osteosclerosis in ball and socket. I'm 57 and was riding my bike 1000 miles a summer for many decades. I also have Vitamin D Resistant Rickets also known as X-Linked Hypophosphatemia, which bone spurs and osteosclerosis are common features, especially as we age with VDRR/XLH. So do I really have arthritis if I have good joint space (no indication of narrowing)? I am having some pain and quit riding my bike for a couple months. Thinking of steroid injection, but I don't want to degrade my cartilage, since it seems like I have good cartilage. Usually bone spurs develop after loss of cartilage, but I think they are a part of my XLH/VDRR metabolism.
9/15/2018 09:47:59 pm
Sometimes a patient will present with more osteophytes (bone spurs) and sclerosis than joint space narrowing. This may simply mean the articular cartilage degeneration is not yet diffuse. Consider it more like potholes. As long as there is some normal thickness cartilage left, joint space narrowing will not be apparent on x-ray. An MRI scan can show such lesions. Ultimately, however, it wouldn't really change the management much. Treatment for osteoarthritis is based on a patient's complaints. If you are experiencing significant pain and stiffness, which is inhibiting your quality of life, and your orthopedic surgeon told you there are arthritic changes seen on x-ray, you would be a candidate for a cortisone injection. This would also help to confirm that the source of your pain is indeed the arthritic hip.
9/16/2018 12:12:51 am
Thanks for clarification and explanation.
11/5/2018 11:24:15 am
Dear Dr. Gorzcnski,
1/18/2019 05:27:22 pm
I apologize for the delay in this response...
1/12/2019 06:45:43 pm
So I’ve been dealing with chronic feet problems for going on 5 years. Plantar fasciitis in both feet which require surgery in both of them. I work retail for years and at my job I was required to move super heavy fixtures during floors moves plus I would go home and run.
1/13/2019 06:45:30 pm
I agree with your second opinion. I do not recommend cortisone injections into or around the plantar fascia, except as an extreme last resort and then only one.
1/18/2019 10:57:46 am
I have had four injections in my hand over the past three years. All four brought pain relief and first two brought immediate relief with no problems. After the third shot I had what I thought was bruising around the site. The same thing happened after the fourth shot although near, not directly at, the injection site. Since then I've experienced what looks like bleeding under the skin twice when using my hand more than normal. I'm concerned that this is a result of the injections and while I've been pleased about having pain relieved, albeit temporarily, I'm concerned about doing damage. Can you advise me about what this apparent bruising/blood leakage might be? I've not experienced it anywhere on my body other than on my hand neat the injection site. Thank you!
1/18/2019 05:12:51 pm
Assuming all 4 of these injections were in the same location, and assuming the injection site was a joint (like the basal joint at the base of the thumb), it is possible some of the steroid has gotten outside the joint. This may have created some atrophy of the soft tissues overlying the joint. This can cause skin discoloration, make the area look depressed, and can make small blood vessels more visible. Depending on the timing of the symptoms you describe in relationship to the injection, it is possible that you were able to overuse the joint without experiencing pain (because the injection was blocking the pain) and actually cause minor injury to the joint or joint lining, this could have caused bleeding.
11/4/2021 09:37:48 pm
If some of the steroid got out of the joint and caused atrophy of the soft tissue, will this tissue return? Would this likely be a factor in continued knee pain? Thank you.
11/4/2021 09:44:25 pm
@Lynette- There should be little to no extravasation of steroid into soft tissues with a properly performed joint injection. If some steroid inadvertently got into the soft tissues and atrophy/hypopigmentation occurred, it is very likely that both of these issues would resolve over time. Gradual recovery can be expected for up to a year.
7/22/2019 06:19:05 pm
I had an X-ray of my right knee in January due to pain. It clearly showed my cartilage, and I have had three different Drs. comment that the knee would likely not need replacement. I also had an MRI, which showed a partial tear of the OCL. Since I was suffering with pain, compounded by Baker's cysts, I agreed to a cortisone injection. The pain has steadily increased, and I returned to my Orthopedic Surgeon last week to request laparoscopic surgery to get to the bottom of this. He took another X-ray, and we were both shocked to see that all of my knee cartilage is now gone. 6 months since the injection. I have read that cortisone can destroy cartilage. I chose not to "believe" it, but I am now convinced that in some cases it is true. I am scheduled for replacement in September.
7/22/2019 08:56:18 pm
I am sorry to hear you are having difficulty with your knee. Based on your comment, however, I do not think it is reasonable to blame cortisone for your trouble.
10/13/2019 11:10:28 pm
Interesting site for information - which leads me to ask a question myself. Was diagnosed with grade 4 knee cartilage defect 12-13mm. At age 50, I’m extremely active and still highly ranked tennis player as well as coaching tennis - so I have a lot of mileage on my knees. Every doctor so far - say I must have surgery - and I realized that it may be what I need to do - but after 6 elbow surgeries from June 2018 to Dec 2018 - and the hard work climbing back up the rankings - I would like to seek different options if any. Got my first cortisone shot in August - Made a 30% relief follow by PRP in August - slightly more relief but nothing spectacular. Was able to finish another tournament- but severely in pain. Rested for 3 weeks/4 weeks and got another cortisone injection October 1st.
10/14/2019 06:29:31 pm
It sounds to me that your problem is an isolated osteochondral defect as opposed to more generalized osteoarthritis based on the question about autograft. If this is incorrect, please let me know and I might have a slightly different opinion.
10/16/2019 12:20:42 am
Thank you Dr. Gorczynski!
10/16/2019 07:08:39 pm
Any of the cartilage reconstruction procedures involves significant time with restricted weightbearing after surgery. All of these procedures have significant unpredictability in terms of completeness of pain relief in the short-term and durability long-term.
11/8/2019 11:11:50 pm
Hello. I am hoping to get some answers here. About 3 months ago I was sitting crossed on the floor and when I stood up I felt a little pain in the inner part of my left knee. 3 weeks went by and the pain were sent to where any time I bent my knee even for seconds when I went to straighten it I would almost collapse. I had an x-ray done and then an MRI and both showed nothing. It is now been 3 months and I have to wear a knee brace every day too get by. The only really if I get is laying in bed. Once I get up in the morning and am vertical the pain starts and is excruciating by nights end. it is now to the point where I can feel the pain all the time. I went to the ortho today and he injected two shots into my knee of steroids. He thought I would feel instantly with one and when I didn't he did a second one. He said I should be a lot better and did no pain even walking to the car. However I was. it is now been several hours and the pain is so bad I am using a cane. I feel like when I put pressure on my knee that it is going to give out completely. It seems to have amplified my issues a great deal. Do you have any ideas on what is going on? Did the steroids make whatever is going on worse? I asked the doctor if this did not work with the next step was and he replied with.... Well then we would be scratching our head because you would be an anomaly. This made me feel very uneasy. nobody can seem to figure out what is causing the pain as the scans do not show anything but it is worsening week by week and now the steroid shots have made it even worse this evening. Is this normal for steroid injections? It feels as if the pain has spread to my knee cap and under my knee cap where before it has been localized to a small c on the inner left knee. The pain has never traveled and there has never been swelling or bruising. But now the pain has traveled and my knee is extremely weak along with my other knee which started hurting last week I assume from favoring at for 3 months.
11/10/2019 06:11:46 pm
The complete lack of response to a cortisone injection into the knee along with normal x-ray and MRI scan suggests the possibility of referred pain.
6/2/2020 11:27:01 pm
Hi Dr. I’ve been so thankful for reading this blog. I am 32 and have a long history of bone trouble starting in my early 20’s. I saw 19 providers, all varied from APRN, PA, DO, MD, and orthopedic surgeons. 7 ortho’s alone. I began having rheumatoid symptoms around 27-28. But my knee issues started around 23. I used to run 5-10 miles per day and lifted heavy weights after working 12 hour shifts at the hospital. My labs were always elevated CRP & SED rate. But RA factor was always normal or one point above range. I was told I couldn’t have RA, even though I had signs and symptoms. 20+ people in my family have it as well. Finally saw a colleague and he said I had Seronegative RA & PsA. Bone scan and xrays ordered. Signal found in both shoulders, both hips, hands, knees, ankles, and feet. At 31 years old. I also have a bakers cyst behind the left knee and a small meniscus tear in the left side. I had arthroscopic on the right knee in 2018. Surgeon said he cleaned up 3 meniscus tears, a small tear in my ACL, and a “ton of debris” from behind my knee cap, and that my Hoffas fat pad was completely shredded. He stated my ACL was super thin and he’d bet that it wouldn’t last much longer without a complete tear. I hurt 24/7 until being put on MTX, Celebrex, and got my first knee injections in February of this year. Just got them again yesterday. The right side faired we’ll both times but the left gets a “cortisone flare” I believe. Extreme pain, swelling, tightness, and a need for the right to work harder. So then the right starts to hurt. I had to use a cane today for the first time ever and I got many stares and the “why are you using a cane and so young?” I felt so embarrassed all day but I genuinely can’t help it. Is this normal? Before the injections and Celebrex, I couldn’t walk more than 20 steps without a break and was falling often due to complete give out. No stairs, working out, or any kind of life. Work 12 hours, home, shower, bed with heating blanket. They have all told me that I’m pretty much almost bone on bone and that I need bilateral replacements but due to my age, that isn’t feasible. I just need the relief from chronic pain but I don’t want pain medicines. I want to function. I’ve enjoyed the gym again and have lost 20 pounds and 40” in 4 months. I lost 30” in my first month and a half at the gym. I’m loving having a life again. But the after of the injection does make me nervous. But after 5-6 days, it went away last time. I’m hoping that is the case this time as well. I also know that you’re to take it easy and not use the joint a lot. I’m 32 and work full time at the hospital, thankfully I am a director now so I’m able to stay in my office mostly and prop the knee up. Just want to know if needing a cane is normal for this kind of thing?
6/3/2020 09:17:23 pm
If you already have bone on bone arthritis, then any theoretical risk of cortisone to the cartilage is irrelevant- you don't have any cartilage left. It sounds like the next step is for total knee replacement surgery. You are definitely young for this procedure. Because of this, when you ultimately decide to proceed surgically, you should also expect to require subsequent revision surgeries throughout your life when the prosthesis wears out or loosens. This is not without risk and it is appropriate to approach this with caution.
6/17/2020 12:31:42 am
Hello. I have a 12 year old child with Oligoarticular JIA, primarily in her left knee. She had it drained and a steroid injection 3 years ago when she was diagnosed, and started systemic meds because she also has Uveitis. She had another injection and her left knee drained again almost 2 years ago. She was still having knee pain, even though she appeared in medicated remission. She also has Ehlers-danlos Syndrome, hypermobility type. An MRI showed an osteochondral lesion of her tibial plateau. Our Ortho said it was minor, and we would watch. A year later and off all arthritis meds, she was still in pain, and a repeat MRI showed the lesion had gotten worse. Our ortho put her in an offloading brace for 6 months. Her arthritis is flaring again, and an MRI last week confirmed synovitis, and the osteochondral lesion remains, but has shown healing in the past 6 months. I've read that some studies show that (especially in growing children) steroid injections into the knees can cause these defects in some people. My ortho and Rheumatologist both said it is unlikely the cause, and her EDS is more likely the cause. Do you have any experience with this happening, or have any good research on the subject? In addition, her knee is currently full of fluid from arthritis. Systemic meds take weeks to kick in. Is it safe to have her knee drained and another steroid injection while the cartilage defect is still present, or could that hinder its healing? Currently, she is to wear the offloading brace 3 more months, then follow up with ortho again. Thanks for any insight or expertise!
6/26/2020 07:03:05 am
I think it is highly unlikely that the steroid injection caused this problem. Also recall, she was having a rheumatologic flare-up for which the steroid was used as treatment. This was appropriate. An osteochondral defect is usually found incidentally, often after minor trauma, and usually in patients that do not have any other known medical issues. It is a fairly common diagnosis in an orthopedic practice. If the lesion will not heal in a reasonable period of time, it can be treated surgically with repair versus resection (removal) depending on the condition of the tissue and age of the patient at the time. This would be done arthroscopically as an outpatient. In her case, it appears that performing synovectomy at the same time would potentially be helpful. I do not think the osteochondral defect is likely to heal at this point based on her history, with or without a steroid injection. This is my general impression of her case, and without seeing an x-ray/MRI, unfortunately I can not be any more specific. This is a challenging situation. Best wishes to you and your daughter.
8/30/2020 05:27:15 am
Hello. IA few months ago had an MRI on my right knee where it was found to have a small minescus tear. I also had x-rays on both knees. X rays showed that I have arthritis in both knees. Dr. told me my options and one was to get cortizone shots. I declined out of fear. Since them I began swimming to try and take some weight off. However both knees have been swollen for past few days (starting to rethink the shots). But I also read something about stem cell replacement for minescus and wondered why I haven't been told about this type of treatment. My sister had two knee replacements. She says shots will not help minescus tears...only arthoscopy will help. Your help is greatly appreciated as I am very skeptical.
9/3/2020 04:58:53 pm
If you already have arthritis in your knees, a degenerative tear in the meniscus should really not the the focus of your attention. Your pain is very likely coming from the arthritis. Cortisone would be expected to temporarily improve pain and swelling. It is not a cure. Stem cell injection is very expensive, and unpredictable. It will not cure arthritis. Arthroscopy is very unlikely to help a knee that has arthritis and a degenerative meniscal tear. This has been historically over-utilized. Many studies have now shown that arthroscopic surgery is really not appropriate for most arthritic knees, regardless of meniscus condition. There is even evidence that arthroscopic meniscal surgery can accelerate degeneration in arthritic knees. I would recommend using cortisone and/or hyaluronic acid injections, keeping your body weight in a healthy range, avoiding high impact activity, and, if surgery is ultimately required, total knee replacement surgery.
9/3/2020 05:05:47 pm
For further information on meniscal tears, check out my blog posting "Why is everyone so fixated on the meniscus?" You can easily find it by clicking on "meniscus" in the right-hand column.
9/13/2020 10:53:27 am
I doubt the cortisone injection has caused any mechanical harm to your knee. There is a tiny chance of developing an infection after any injection, so if you are getting worsening pain, fevers, chills, redness, swelling, or stiffness I recommend you contact your surgeon right away.
Thank you so much for the reply! The knee pain did not resolve and the overall pain level is slightly more. I believe that this may also be due to stoping PT and not using the leg as much. The character of pain has changed. Before it mostly ached all over my knee cap. Now it's more of a sharper consistent pain. The knee itself also seems less stable. I wrap a bandage around it only when I am driving or going up and down the stairs, which seems to help.
9/20/2020 02:46:25 pm
I sounds like you are doing all the proper things. I would recommend focusing on optimizing hip strength. Think of your hip as the foundation of your lower extremities. The stronger your hips, the more protected your knees are.
9/13/2020 12:41:13 pm
I went in for patella tracking disorder diagnosed three years ago. A few weeks ago, my knee was a little swollen and not really painful but the kneecap grinding and floating uncomfortably out of place. Next thing I know I’m getting a cortisone shot during that visit. Now I can’t even walk with the pain. Tell me it didn’t do permanent damage! I didn’t even have time to research this and now I’m disabled.
9/13/2020 07:02:34 pm
I doubt the cortisone injection has created any permanent damage. It is an anti-inflammatory medication. If you are feeling significantly worse, I recommend you contact your surgeon for re-evaluation and to discuss additional treatment options.
9/30/2020 04:58:46 pm
Hi: I'm really concerned that the one shot I had to my knee is going to break down my knee cartilage. My pain wasn't terrible, but my doctor was gung-ho on trying the steroid.
9/30/2020 07:07:26 pm
Your question is exactly what prompted this article.
11/26/2020 01:57:27 pm
I perform hip arthrogram injections routinely in the office. This procedure takes less than 5 minutes and there are no subsequent restrictions. I do not use any sedation so patients can drive home immediately afterward.
11/24/2020 11:23:50 am
I had an MRI done and it stated high grade focal chondral defect of the posterior central aspect of femoral condyle measuring 1.4 x .6 cm in AP and transverse dimensions. small knee joint effusion and synovitis. I went to the orthopedic and he gave me a cortisone shot to try. He said surgery is a 50% chance.. I have heard about microfracturing. Do I suggest this to him?
11/26/2020 09:56:28 pm
I agree with your treatment thus far. I presume the surgery he would offer you would be arthroscopic evaluation with microfracture. This is the standard of care for such a lesion. This is a simple procedure that is likely to help you, since you have what sounds like an isolated, contained cartilage defect. This is exactly what I would do for you. Assuming this is truly an isolated defect, I believe you have much better than 50% chance of improvement- I would guess 75-80%. That does not mean perfect, or normal. But I would not expect ongoing, excruciating pain forever with a lesion like you describe. If you have ongoing symptoms after surgery, you could also consider hyaluronic acid injections and/or platelet rich plasma injections. There are more complex reconstructive procedures you would be a candidate for in the unlikely event you did have significant ongoing knee pain including OATS or ACI. These involve transplanting cartilage into the defect. I would not recommend either of these procedures as a first-line surgical treatment because micro-fracture is usually all that is necessary.
11/24/2020 02:56:35 pm
I had a THR less than 4 and a half years ago. It healed, but for the last couple of years I have what feels like inflammation with weakness and limited motion doing a side leg lift on the outside. I had a weaker leg on that side anyway due to a mild CP. My question is can I have a cortisone shot in a tendon or bursa around the THR? When I requested one, I was told no because of concerns about an infection developing. I am in pain frequently, not as active as I want to be, and I don't see any other option to feel better. I also have a question about should I need a replacement can it be replaced with ceramic instead of the Stryker and some other name I had put in? Thank you. I am 62.
11/26/2020 10:17:53 pm
In general, we try to avoid any invasive procedure (including injections) around a joint prosthesis. Occasionally, for a significant ongoing problem (like bursitis) or for diagnostic purposes, I will offer an injection near a prosthesis after careful risk/benefit discussion with the patient.
12/1/2020 12:09:34 pm
Hi Dr. G - I have been a runner for over 10 years and started having knee pain 2 years ago, coming immediately after I did some lower body strengthening exercises one day in Aug 2018 (lunges, squats, etc. with weights). Would get dull to sharp pain in my left knee everytime I ran after that. Resting would help but the next time I ran, it would hurt again. I stopped running for a few months and then got pregnant (November 2019) and interestingly was able to run while pregnant without much pain. I stopped running for several months after giving birth and then broke my toe so couldn't run for a couple months more. Tried to run again this summer (June 2020) but pain came back. Started even get pain walking for a few hours sometimes too. First doc I saw said it was tendinitis and had me try PT. After a couple months of PT, I didn't see improvement so I had an MRI which noted "No Chondromalacia Patella identified" and "Intermediate T2 signal anterior. cruciate ligament, nonspecific in absence of trauma." My doc then gave me a cortisone shot and things took a turn for the worse. I couldn't even bend my knee fully the first week after and pushing off my knee from a squat position still gives me pain (it's been 5 weeks since I had the cortisone shot). Even walking for only 20 minutes now brings me pain - worse pain than before. I saw a different doc who said it's a combo of "Symptomatic Right patellar chondromalacia, Patellar Maltracking, Flatfoot/Hyperpronation with walking" and he wants me to try PT again, which I will do but I'm really skeptical because it didn't work the first time. I'm also extremely concerned about the pain I'm having post-cortisone shot and am very scared by the thought I might never be able to even walk for long periods of time again. I was so active and not being able to walk would be a devastation - I am crying just thinking about this. My questions for you are:
12/7/2020 08:47:34 pm
I agree that physical therapy sounds like your best option. It is important for your surgeon/physical therapist makes sure your hip flexors, abductors, and external rotators are properly rehabilitated. These need to be strong and symmetric. It is very common for a patient to have knee pain, which is a result of hip weakness. As I can not examine your hip, I can not prove this, but I am very suspicious of this based on your history. Typically knee pain that results from hip weakness will not improve significantly with a cortisone injection.
12/7/2020 09:33:30 pm
Thank you for taking the time to read the details of my situation, Dr. Gorczynski. I greatly appreciate it. Your article on anterior knee pain did remind me of something...several years ago, I started noticing my hip flexors would bother me often (usually after long runs/lots of activity). I'd get the feeling like I'd need to stretch them out. Could that be a sign of weak hip flexors or malalignment of my overall positioning? Would fall into your theory that PT focus in that area (among others) is needed!
12/14/2020 10:24:34 pm
This sounds like a rare "flare" reaction in response to the steroid injection. This is an unusual, acute increase in pain following the injection. It is thought to be a result of rapid uptake of the steroid crystals into the synovial cells. It is usually self-limited and resolves within a few days. Your situation sounds a bit more persistent. I recommend having your surgeon keep a close watch on your situation with a low threshold for repeat imaging if things don't improve soon.
2/11/2021 05:00:12 pm
DO YOU BELIEVE THAT ONE INJECTION OF 20mg of Kenalog into Hoffas fat pad could cause any problem
2/14/2021 10:13:10 am
3/21/2021 06:25:27 am
I have gripping sensation above my ankle whilst walking and foot uncomfortable..Dr injected nerve block into side of my leg.and local an aesthetic into top of foot. The nerves in my leg and foot were “electric” afterwards!!
3/28/2021 11:22:31 am
Usually a cortisone injection is done into a joint for treatment of arthritis. The diagnosis of arthritis means your cartilage is already very damaged. These treatments were done in an attempt to treat the symptoms that are a result of the degenerative cartilage disease you already have. As a patient it is important that you understand what your problem is, and how a procedure may help. These are reasonable questions for you to ask your surgeon, before a procedure is performed.
4/11/2021 10:50:43 am
I was recently diagnosed with hEDS and have concerns about how to work with my abnormally loose joints. All the literature I have found suggests that with my collagen defects, I should avoid cortisone shots and surgery, but most doctors don't seem to know much about the condition and still recommend the shots. Any thoughts on this?
4/13/2021 08:09:01 pm
If you have symptomatic arthritis, you have limited options. If oral medications aren't helping you, I would consider either cortisone injection, hyaluronic acid (lubricant) injection, PRP injection. The alternative would be joint replacement surgery. If the main issue is joint instability, only surgery will help you. Your surgeon will need to have more constrained joint replacement prostheses available to use, since your ligaments can not necessarily be trusted to support your reconstructed joints.
4/14/2021 06:59:42 am
4/25/2021 10:33:56 pm
A labral tear (including SLAP) is usually visible on standard MRI. An MRI arthrogram (intra-articular contrast is injected prior to MRI) will increase the sensitivity of this test. Cortisone is not expected to decrease a joint range of motion, usually the opposite. It sounds like you may have arthritis in your shoulder. That should be apparent on standard x-rays (particularly the axillary view where joint space loss will be obvious, and the AP view which will reveal an inferior humeral head osteophyte (bone spur)) Cortisone can take several days to take noticeable effect.
4/17/2021 09:11:23 am
Hi, had a quick question. I had MACI done on my knee 1 year ago and the pain has gotten worse. My doctor gave me a cortisone shot yesterday. Was it a good idea to have this done with the new cartilage?
4/25/2021 10:25:35 pm
If you are having pain a year following the procedure, I think it is completely reasonable, and low risk to undergo a cortisone injection. I would argue that if the new cartilage was working properly you wouldn't be having pain. Also consider hyaluronic acid injection/platelet rich plasma injection. If injections fail, you would be a candidate for arthroplasty. Unfortunately, there are not many treatment options, so under the circumstances cortisone is simple, usually effective, and reasonable risk. Best of luck!
5/23/2021 11:06:26 pm
I had a cortisone injection into my vmo quad. I have had 3 months of pain above my knee. Have tried a cortisone injection into my knee and it did not help prior (about 5 weeks ago). 6 weeks of PT that made me worse. I took 2 mri’s. The most recent MRI just showed an edema above my knee (medial). I have a pretty large bulge that won’t go away in that area. Most pain is in that area and sometimes directly above the knee and sometimes to the left of that. I am in pain 3 days after this most recent injection. I am reading that it was maybe dangerous to get the injection in this area (vmo area)? Should I be concerned? I am in more pain right now, but maybe due to the injection and in an already inflamed/swelled spot...thank you
6/23/2021 10:43:32 pm
I would not be too concerned about a single injection of low dose steroid into this area. It sounds like it did not help much though, so I would be reluctant to consider repeating it. The steroid is a powerful anti-inflammatory medication, so it was reasonable to consider. Since it did not help, I sounds like you need to rule out other things. Definitely follow-up with your surgeon.
5/31/2021 06:28:57 pm
I had two medial meniscus surgery. Apparently after the first surgery I tore it again. The second time, a different surgeon took out the synovial membrane. My knee has not improved. Is it common to take out the synovial membrane. What would be some of the reason for doing this?
6/23/2021 10:27:23 pm
Removal of synovium (partial synovectomy) is done to prevent recurrent swelling in the knee.
6/2/2021 04:30:24 pm
Can a headache be a side effect of the shot? I felt kinda weird all day and woke up with a headache. Kind of a rough night sleep. Hopefully tonight is better.
6/23/2021 09:11:00 pm
While just about any symptom has been described as a side effect of just about every medicaiton (and this includes dizziness/headache after steroid injection), headache following cortisone injection is not a common complaint I hear from my patients.
8/16/2021 12:34:51 pm
Hello I was reading a couple of your responses and then was wondering if you'd give me some insight on my knee issues. I have had pain in both my knees in the last year. My right knee has been giving me pain for the last 2 and 1/2 years. A few months ago in May I had an MRI done on the right knee due to the pain on the anterior and posterior and swelling on the right knee. I received cortisone shots in both my knees and it seems it made the pain worse. My knee in the right feels like it is going to buckle sometimes. If I stand for a long period my niece swells really badly. Also it is painful to my knee when I bend my leg. I am set to go to PT but I'm wondering if this is just a waste of time and is the findings something that should have me going to need surgery. Originally before the MRI, I was asked by the x-ray staff if I had ever had surgery done on my knees before because there was a hole that looked like I had had surgery on my knee. Here are the results of my MRI to the right knee below. I would love to hear your insight;
8/19/2021 04:18:32 pm
You are developing patellofemoral arthritis. It is crucial to maintain very strong core/hip muscles with this condition. Check out this article:
3/8/2022 03:08:05 pm
I am not sure what I have! I had a bike accident in 2019, took a week off from cycling as I was recovering from a running injury. After a bike ride, my quad/right knee swelled up. I was diagnosed with chondromalacia. Lots of PT. I'm 51 now. I have tried to start running again, only to experience a lot of grinding, clicking, clicking in the knee. I feel pain especially under the kneecap, usually the lower half. I've had three cortisone shots in my knee, usually one a year. I just had my third a week ago, and the pain under my kneecap is not much better. I do want to keep running and my ortho likens that to playing Russian roulette with my knee. He knows I'm passionate about it, but he looks at me like I'm nuts. To this point my treatment has been conservative. He's the third doctor I've seen about this. They all say nothing is wrong with my knee. I say BULL. It wouldn't hurt if nothing was wrong. I think it's a tracking issue, but my ortho says I'm developing arthritis under the kneecap. His notes said I have patellofemoral syndrome. My question - can I still run? Will I do more damage? Walking is ok but that's not what I want to do. I'm honestly terrified to do anything.
4/9/2022 07:13:58 pm
Chondromalacia means your cartilage is breaking down. This accounts for the grinding sensations and pain. This eventually will become arthritis. Arthritis means most/all of the articular cartilage has worn away. Patellofemoral syndrome suggests anterior knee pain, often due to weakness of the core/hips. This can occur independent of chondromalacia. The kneecap takes tremendous load when you run. Your doctors have suggested not running to help minimize overloading your patella, and accelerating the degenerative process. Without seeing your x-ray/MRI, I can not really comment any more.
3/12/2022 05:35:36 am
Having a worrisome situation.
4/9/2022 07:16:41 pm
Unfortunately, I do not think there is anything that can be done once an injection has been placed into the soft tissues. Hopefully, everything worked out OK for you.
5/26/2022 01:46:44 am
I have lost over 50% of my cartilage under knee cap. I should be able to have surgery (where they take cartilage from a donor that has passed and transplant to me) in the next 6 months or so. My knee has been like this for two years. I wait a year and a half to have surgery just to find out insurance required my BMI to be lower so now I’m in process of losing the 40 pounds I need off. My knee has been bothering me a lot more (mostly at night while trying to sleep) my whole has drastically changed since this injury (I stood up my knee popped -I tore the meniscus and a bunch of cartilage slid out- I had meniscus fixed 2 years ago). So I don’t do a whole lot . In the past I have had cortisone shots for many things and my body seems to respond well to them. Would a cortisone shot help with the pain (right now all I take is one 500mg naproxen at night. I could take them twice a day but I am not tying to kill my liver). I need something to help me with the pain for the next 4 while I get the rest of this weight off.
7/9/2022 02:59:31 pm
A cortisone injection is likely to help your pain temporarily. You do not mention your age, but since your surgeon is planning an osteochondral allograft reconstruction of your patella, I assume you are young. Generally patients with patellofemoral arthritis (who are of reasonable age) will have a more predictable result with patellofemoral replacement. What is reasonable age? An excellent question. There is not a "correct" answer here. This should be individualized- and requires a discussion between patient and surgeon. Options include continuing non-operative treatment (using cortisone, hyaluronic acid, platelet rich plasma injections, weight loss, NSAIDS, ice, physical therapy, etc), proceeding as planned with osteochondral allograft reconstruction, doing prosthetic patellofemoral replacement, or doing total knee replacement. I would predict each of these options will likely result in eventual total replacement. This is where stage in life and risk/benefit analysis must be done. Again, this is a conversation that should occur between patient and surgeon. If you are young (<30) and surgery is truly required due to severe, unrelenting anterior knee pain, resistant to all nonoperative options, then your current surgical plan is reasonable, and I would encourage you to avoid any steroid injections.
5/27/2022 03:48:53 pm
Hello, I've had a set back in my recovery from a tiny fracture of the cuboid bone in my foot (injury 1/9) and just received an MRI. It reads in the impression section: “unchanged mild reactive marrow edema cystic change in the calcaneus likely reactive to insertional Achilles enthesopathy.” I'm wondering what can be done to help alleviate my pain, which is mostly on the right side of my foot. Thank you.
7/9/2022 02:47:28 pm
Generally, a short period of rest/immobilization followed by some physical therapy should improve this condition. If not successful, occasionally an operation could be required to debride/repair the achilles tendon.
8/28/2022 06:03:10 pm
4 weeks after a cortisone injection in my hip my hip collapsed. Why would that happen?
8/28/2022 09:45:30 pm
This is a rare complication of intra-articular hip joint injection. Several case reports appear in the literature. Although this has been described, and I have seen this exact thing happen, cortisone injection remains an accepted treatment for degenerative joint disease of the hip. The main reason for this is that the vast majority of hips that undergo cortisone injection are being treated for arthritis. If this treatment fails the patient must undergo total hip replacement. In the unlikely event the hip collapses (less than 3% chance of collapse), the treatment is a total hip replacement. So the patient really doesn't lose much by trying. Seen the other way- if we deny this treatment to all patients, then 97% of patients that would not have experienced this complication must then go directly to total hip replacement. Here is a link to a case report:
1/11/2023 11:28:52 pm
I am a 52 year old male with stage 4 knee osteoarthritis. I tore my right ACL at 17 (repaired) with patella tendon graft. Since then, I have had 2 surgeries since then to clean things out. I ski, hike, and a mountaineer. I have been receiving cortisone injections for the past 2 years and now I have found that only Depo-Medrol works and Keelogs does nothing. Still even after shots, stiff but no pain for a few months. I am struggling with the decision for TKR. Doc does not encourage Synvisc. Is it time? I work as a PE teacher and I am constantly on my feet and moving.
1/16/2023 11:36:38 am
While not every patient gets relief from viscosupplementation (synvisc, orthovisc, euflexxa, etc), there is no real downside to trying it. When the alternative is total knee replacement at age 52, I certainly would try it.
A 63 year old male with history of osteoporosis problems, Hallux Rigidis, Rotator Cuffs, replacement right hip in recent years, my left knee patella identified as very rough on the underside catches and causes me immense pain particularly at night, I keep it braces with a sports support, I also have left groin pain too, I do know my knee is not in the best shape, would injection of cortisone postpone the inevitable! Knee replacement, incidentally I have played 2500+ football games finishing g at 45 y.o.
4/15/2023 08:23:51 pm
I’ve been getting Zilretta shots about every 4 months, starting in Dec’ 21, in both knees that have medial bone-on-bone (Stage 3). The good news is that I feel great for about 9 weeks, so-so for 2 more weeks, and then things quickly worsen (pain-wise) before I get my next shots. My knees can swell in between shots, resulting in fluid being drained from one or both. My doc then waits ~ four weeks (if this happens) to inject Zilretta. I've been hearing that Euflexxa can be used with Zilretta, but it should be after it. Prior to getting my first Zilretta shot, I had previously used Euflexxa with some success (over 4 – 5 months of relief), but my insurance doesn't cover it. I'd really like to get off of cortisone but am afraid that Euflexxa might not be as effective on its own almost two year later (my last gel shot was in June ’21). That said, what are your thoughts about using these together? How long should I wait in between or does that matter? Thanks!
5/7/2023 03:13:43 pm
For my patients, I would use cortisone or zilretta as frequently as every 3 months. It sounds like that could be the solution you need. Assuming your insurance would cover it at that frequency, you should be in good shape for a while. I will occasionally use hyaluronic acid alternating with cortisone, but I do not generally use both at the same time. I would wait at least 6 weeks between these injections if you are using them this way. It sounds to me that you knee is nearing the point that knee replacement surgery needs to be considered. After surgery, most patients feel they waited too long prior to their knee replacement. Best wishes!
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