Having just reviewed the medical literature in preparation for a presentation on corticosteroid injection at the annual ACFAS meeting, Paul Dayton, DPM, says that evidence will change the way he uses corticosteroids going forward.
In some cases, such as for postoperative pain relief, he’ll be more likely to turn to corticosteroids than in the past. But in most cases, he’ll be saying no to the needle much more frequently. And he thinks most practitioners probably should do the same.
“Corticosteroids are used all the time, indiscriminately. It’s not based on evidence,” said Dayton, who practices with Trimark Physicians Group and is director of podiatric medical education for the Trinity Regional Medical Center residency program, both in Fort Dodge, IA. “People have done it for years, and they do it just because it’s been done.”
Intra-articular injections are particularly problematic because the benefits may be overestimated and the risk of complications underappreciated. Studies of steroid injection to relieve degenerative pain in various joints suggest that the positive effects last no longer than six months and do not ultimately obviate surgery. In a 2001 study, for example, steroid injections were associated with six months of symptom improvement in patients with degenerative joint disease in the first metatarsophalangeal joint, but two thirds of those patients still underwent surgery within a year.
“My sense is that we’re letting patients think it may be a cure when we know it’s really not going to be,” Dayton said. “You have to tell patients it’s just a temporary measure.”
Not only that, but the literature contains multiple reports of joint dislocation following intra-articular steroid injection, as well as tendon and ligament rupture following soft tissue injection.
“It may not be the steroid effect that causes the joint to dislocate. It may be that the steroid made the patient more comfortable so they went out and did something else that caused it,” Dayton said. “But if you’re the last guy to have seen the patient before the dislocation happens, you don’t want to be there with the needle in your hand.”
Other complications have been documented as well, including a risk of persistent hyperglycemia in patients with diabetes following soft tissue steroid injection. At least two studies also suggest that a recent history of steroid injection has an adverse effect on infection rates following total joint arthroplasty.
On the other hand, Dayton said he was surprised to learn that the postoperative administration of corticosteroids in multiple studies of knee and foot surgery was associated with significant pain relief and decreased analgesic use.
“I was trained that postoperative steroids were unnecessary and of no benefit,” Dayton said. “But the literature actually supports it.”