• Why Shouldn’t I Get Steroids for My Joint Pain?

    The other night at handstands class (yes, that’s my favorite weeknight activity, and no, I am not aggressively too old for it), several of my fellow handstanders discussed the merits of getting a shot of steroids for knee pain. I think. Some sort of joint pain for sure. One person shared their experience of dramatic pain relief as a result of a similar treatment and encouraged the questioner to go ahead with it.

    Throughout this discussion I sat silently, keeping the information in this post to myself. Because no one likes a know-it-all, and nobody ever likes someone telling them not to get quick pain relief. In Texas, “shoot the messenger” is not a metaphor, and this definitely qualifies as a messenger shooting situation.

    Today I feel kind of bad about it though, but not bad enough to try to contact this person. I have just enough guilt to write this post instead of the other ones I had planned, and I think both my grandmas would agree that’s just about the perfect amount of guilt. #ThanksGrandma

    So, now that I’ve admitted to a grandma sanctioned guilt complex, let’s talk about steroids and why you should probably never get them. For joint pain.

    Steroids Treat Joint Pain

    for short periods of time.

    Doctors started using corticosteroids, to treat joint pain somewhere between the hay days of the T-Rex and the velociraptor, because they work well for a percentage of patients. But, the pain relief is fairly short-lived. In a review of 28 studies involving 1973 patients, corticosteroid joint injections relieved pain more effectively than a placebo injection for time periods of weeks, not months. In another review of 312 patients who received corticosteroids for their painful knees, pain relief lasted for a period of 3-4 weeks. The pain relief usually falls within the range of 75% at the maximum relief point and then climbs back up over time.

    So if you want pain relief for a few weeks, steroids are an ok option. As long as you read the fine print. And the fine print gets pretty hairy. In fact, the likely de-emphasized side effects of steroid injections remind me of literally every pharmaceutical advertisement I see on the gym TVs. A whispered voice or size four font appears in the last 5 milliseconds of the ad to tell you:

    “Vitallegra KP may cause sleep crime, tooth melting, fingernail reversal, circus related Tourette’s, horrifyingly realistic dreams about giant frogs, Scrabble addiction, nicotine addiction, shingles, and cheese allergies.”

    They technically told you about the side effects, but you completely miss that all important cheese allergy announcement. Nothing is worth gaining a new cheese allergy, y’all. And that’s why we’re covering these steroid side effects in black and white, slow mo, normal size font.

    Steroids May Cause Tendon Rupture

    I say that with some ambiguity, because no study confirms that steroids directly cause tendons to explode. But if you take a look at this small sampling of quotes, all from scientific publications, you’ll notice a disturbing trend.

    Glucocorticoid-induced tendon rupture is very common in clinical practice.

    Corticosteroid injection is commonly used to treat tendon injuries but is often associated with tendon rupture and impaired tendon healing

    It is clear that the local administration of glucocorticoid has significant negative effects on tendon cells in vitro.

    Serious adverse effects have been reported as a result of [corticosteroid] treatment, such as impaired tendon healing and tendon rupture.

    Every one of those quotes links out to the associated study, because references matter, y’all.

    Steroids Damage Tendon Cells

    Now that you’ve seen the headlines, let’s get a little more specific here so you can weigh the evidence properly.

    • This review of 13 studies says tendon rupture and atrophy happen more frequently after steroid injection than placebo
    • This one  says that two different types of steroids decreased the tendency of tendon stem cells to become tendon cells (that’s bad) and slowed down the rate of cell growth (also bad).
    • In this study, even the lowest steroid dose increased expression of “dormancy” genes. So basically the cells go into retirement and stop doing the thing they’ve done their whole lives. It sounds like a great vacation for those cells, but your tendon might explode as a result.
    • In this study, steroids killed human tendon cells, decreased their ability to make new cells, and slowed collagen production.
    • In this one, steroid treatment decreased live cells and collagen production for at least two weeks.

    I left a longer list of references at the end of this post. Just in case you want to really dig in to this one rabbit hole. But even if you don’t read any further, the trend should be clear. Steroid injection leads to cell damage and tendon rupture. 

    But tendons aren’t the only thing steroids mess up.

    Steroids Damage Cartilage

    These poor horses had steroids injected repeatedly for two months, and it just damaged their cartilage. The study tested the mechanical properties before and after the injection cycle. And it turns out that the steroids made the cartilage weaker, more permeable, and thinner.

    This giant study (of other studies) offered a literal smorgasbord of cartilage damage:

    • 6 studies | loss of collagen organization
    • 3 studies | collagen loss
    • 17 studies | decreased collagen production

    In another big study (of other studies), the authors had this to say about normal clinical doses of steroids :

    …corticosteroids were associated with significant gross cartilage damage and chondrocyte toxicity

    So steroids hate basically all the tissues in your joints and want them to die. That’s the moral of the story so far.

    Steroids Aren’t Worth It

    Sure you get short term pain relief. But at what cost? Is four weeks of pain relief worth speeding up the breakdown of your cartilage and tendons? Or the risk of literal tendon explosion*?

    *no, they don’t explode like fireworks. But every time I read “tendon rupture” I imagine one of those coyote and roadrunner BAM signs appearing. So I stand by my decision to call it an explosion on cartoon-related principles. #IDoWhatIWant

    Back to the ranch – are steroids worth the risk of completely messing up your joint/tendon?

    I don’t think so, and that’s why none of the people I love ever get the green light from me when they ask about steroid injections for joint pain.

    Now, qualifier: there are cases in which steroids are absolutely necessary. Sometimes inflammation gets so out of control that steroids literally save lives. But looking at your everyday average arthritis related joint pain, you should run as fast as you can in the opposite direction of steroids. Possibly in the direction of some of these joint friendly alternatives.

    There Are Steroid Alternatives

    Hyaluronic acid, platelet rich plasma, and bone marrow concentrate all have associated clinical studies that show significant pain relief. Without the tiny side effect of aggressively maiming all the cells you’re trying to fix in the process. And they take about the same amount of time as a steroid injection.

    So next time someone recommends steroids for your joint pain, ask if they have an alternative that isn’t terrible. Because getting a steroid injection for arthritic joint pain is like going to a loan shark to pay off your bookie. (Yes, y’all, I do watch a lot of CSI.) Your problem goes away temporarily, but two weeks later you’re way worse off than before.

    So why shouldn’t you get steroids for joint pain (unless you absolutely have to)? Because they literally damage your joint tissue and lead to more pain.

    Alright kids, that’s it for this soapbox. For more information, feel free to browse the list of references below. If that’s not your style, leave a comment or drop me a line.

    References No One Wants To Read

    1. Murray RC, Debowes RM, Gaughan EM, Zhu CF, Athanasiou KKA. The effects of intra-articular methylprednisolone and exercise on the mechanical properties of articular cartilage in the horse. Osteoarthr Cartil. 1998;6(2):106-114. doi:10.1053/joca.1997.0100
    2. Zhang J, Keenan C, Wang JH-C. The effects of dexamethasone on human patellar tendon stem cells: Implications for dexamethasone treatment of tendon injury. J Orthop Res. 2013;31(1):105-110. doi:10.1002/jor.22193
    3. Nuelle CW, Cook CR, Stoker AM, Cook JL, Sherman SL. In Vivo Toxicity of Local Anesthetics and Corticosteroids on Chondrocyte and Synoviocyte VIability and Metabolism.
    4. Dean BJF, Lostis E, Oakley T, Rombach I, Morrey ME, Carr AJ. The risks and benefits of glucocorticoid treatment for tendinopathy: A systematic review of the effects of local glucocorticoid on tendon. Semin Arthritis Rheum. 2014;43(4):570-576. doi:10.1016/j.semarthrit.2013.08.006
    5. Spang C, Chen J, Backman LJ. The tenocyte phenotype of human primary tendon cells in vitro is reduced by glucocorticoids. BMC Musculoskelet Disord. 2016;17(1):1-9. doi:10.1186/s12891-016-1328-9
    6. Coombes BK, Bisset L, Vicenzino B. Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: a systematic review of randomised controlled trials. Lancet. 2010;376(9754):1751-1767. doi:10.1016/S0140-6736(10)61160-9
    7. Fredriksson M, Li Y, Stålman A, Haldosén LA, Felländer-Tsai L. Diclofenac and triamcinolone acetonide impair tenocytic differentiation and promote adipocytic differentiation of mesenchymal stem cells. J Orthop Surg Res. 2013;8(1):2-7. doi:10.1186/1749-799X-8-30
    8. Yang, Shu-long, Yu-bo Zhang, Zhi-tao Jiang, Zhao-zhu Li and DJ. Lidocaine Potentiates the Deleterious Effects of Triamcinolone Acetonide on Tenocytes. Med Sci Monit. 2014;20:2478-2483. doi:10.12659/MSM.891116
    9. Chen W, Tang H, Zhou M, Hu C, Zhang J, Tang K. Dexamethasone inhibits the differentiation of rat tendon stem cells into tenocytes by targeting the scleraxis gene. J Steroid Biochem Mol Biol. 2015;152:16-24. doi:10.1016/j.jsbmb.2015.04.010
    10. Scutt N, Rolf CG, Scutt A. Glucocorticoids inhibit tenocyte proliferation and Tendon progenitor cell recruitment. J Orthop Res. 2006;24(2):173-182. doi:10.1002/jor.20030
    11. Poulsen RC, Watts AC, Murphy RJ, Snelling SJ, Carr AJ, Hulley PA. Glucocorticoids induce senescence in primary human tenocytes by inhibition of sirtuin 1 and activation of the p53/p21 pathway: In vivo and in vitro evidence. Ann Rheum Dis. 2014;73(7):1405-1413. doi:10.1136/annrheumdis-2012-203146
    12. De Mos M, Koevoet WJLM, Jahr H, et al. Intrinsic differentiation potential of adolescent human tendon tissue: An in-vitro cell differentiation study. BMC Musculoskelet Disord. 2007;8:1-12. doi:10.1186/1471-2474-8-16
    13. Zhang J, Wang JHC. Characterization of differential properties of rabbit tendon stem cells and tenocytes. BMC Musculoskelet Disord. 2010;11. doi:10.1186/1471-2474-11-10
    14. Wernecke C, Braun HJ, Dragoo JL. The effect of intra-articular corticosteroids on articular cartilage: A systematic review. Orthop J Sport Med. 2015;3(5):1-7. doi:10.1177/2325967115581163

    Photo by Justyn Warner on Unsplash