Could Injections Relieve Osteoarthritis Symptoms? When to Choose Steroids or Joint Fluid to Combat Pain and Stiffness

If over-the-counter medicines aren’t relieving your osteoarthritis pain and stiffness, but you aren’t ready for joint surgery, there’s a middle ground: injections of steroids or a joint-fluid component directly into the affected area. Could this be the right osteoarthritis treatment for you? When osteoarthritis gets severe, the pain can be debilitating. So what can you do about this degenerative joint condition, generally brought on by aging or overuse of the joints? You may take over-the-counter pain medications like acetaminophen (Tylenol) or non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Advil) and naproxen (Aleve) to relieve your osteoarthritis symptoms. But they may not provide total relief – and as you increase NSAID doses, you may also be facing other health risks. “Non-steroidal anti-inflammatories are good first-line treatments for osteoarthritis symptoms,” says Patrick McCulloch, M.D., an orthopedic surgeon at the Methodist Center for Sports Medicine in Houston. “The problem is that [eventually] they can contribute to gastrointestinal ulcers and bleeding, as well as high blood pressure, kidney damage, heart problems and stroke.” That’s one reason an injected osteoarthritis treatment – either corticosteroids to reduce inflammation or hyaluronic acid to cushion joints – is an increasingly attractive osteoarthritis treatment option. Not only do they help relieve pain and stiffness, but they may allow some patients to postpone joint-replacement surgery. If medications aren’t helping your osteoarthritis symptoms – or if they’re causing harmful side effects – ask your doctor whether injections could help. Here’s the lowdown on each of the two options: Osteoarthritis treatment #1: Corticosteroids These steroid hormones relieve inflammation when injected into a painful joint. Although inflammation isn’t part of the osteoarthritis disease process (as it is with rheumatoid arthritis), it can still be a factor that triggers pain, says Robert Salk, D.P.M., a podiatrist at Northern California Foot and Ankle Center in San Francisco who has researched the use of injections for osteoarthritis symptoms. When osteoarthritis creates bony growths, called bone spurs or osteophytes, inflammation can occur around the joint, Salk explains. Sometimes spurs break off, causing a bone fracture that also leads to inflammation. How do they work? By reducing inflammation and the number of inflammatory cells and decreasing temperature (another sign of joint inflammation), McCulloch says. When do doctors recommend them? They’re generally preferred if NSAIDs no longer relieve pain at a safe dose, and if you have only one or two painful spots – such as knees or ankles. Physicians inject the medication directly into the painful area, says McCullough. That way, it relieves osteoarthritis pain without distributing the medicine throughout your body, which would increase the risk of side effects. Are they an effective osteoarthritis treatment? They’re very good at decreasing osteoarthritis pain and increasing joint function, says family and sports physician Jamie F. Peters, M.D., medical director of Fairview Sports and Orthopedic Care in Eden Prairie, Minn. “They can allow increased function for 3-4 months, even if you have significant damage,” he says. But not everyone gets long-term benefits, says McCulloch. “If someone gets six months [of pain] relief, then an injection once or twice a year is a reasonable treatment,” he says. “But if you only get six weeks’ relief, it doesn’t make sense to inject corticosteroids again.” Do they prevent the need for surgery? “If injections help, then it’s reasonable to delay surgery,” McCulloch says. They may also be an effective remedy for elderly patients when joint surgery isn’t an option. What are the side effects? “Steroids can weaken ligaments or tendons,” Salk says. “That’s why doctors usually do no more than three injections a year.” And some forms can leave crystals in the joint, injuring it further. But with occasional use, most side effects are rare, says McCulloch. The skin at the injection site may become lighter or irritated for 24 hours – “but that’s in less than 1% of patients,” he says. Some people may also experience a short flushing sensation, which means some of the medicine has passed into the bloodstream. Also, diabetics may have a small increase in blood sugar levels. To help minimize these effects, avoid strenuous activities for 48 hours after an injection, advises Salk. “The ligaments and tendons can develop tears and the activity could make the cortisone dissipate – you want to keep it localized,” he says. How do corticosteroids compare to hyaluronic acid injections? Recent studies suggest that corticosteroids are best short term. When injected into a knee, they were more effective for osteoarthritis pain than hyaluronic acid during weeks 1-4; by week 4, the two were equally effective; and after week 8, hyaluronic acid proved the winner, according to a 2009 Tufts University analysis of seven trials involving 606 people. Osteoarthritis treatment #2: Hyaluronic Acid (HA) HA is a thick, gooey fluid produced in every joint. The form that’s injected is made from rooster combs. How does it work? It’s a natural joint lubricant, providing a cushion that helps absorb stresses. Injecting HA into the joint offers even more cushioning, says Salk. “If you look at the joint fluid in someone with osteoarthritis symptoms, it’s very thin and watery,” he says. “When you inject hyaluronic acid, it replenishes the normal fluid.” Supplementing HA also seems to trigger more of your body’s natural production. “After 3-5 injections, you may have a year or more of relief, even though the medication [itself] is out of the body within a few days,” Salk says. “That’s why we theorize that it stimulates the growth of new hyaluronic acid.” When do doctors recommend it? If NSAIDs and corticosteroids don’t offer enough relief, your doctor may prescribe it. “It works best for mild to moderate osteoarthritis,” Salk says. In later stages, there’s little space and natural fluid left at the joints – so HA may be less effective, he says. Is it an effective osteoarthritis treatment? “Two out of three patients get relief [from osteoarthritis symptoms] and feel it was worthwhile,” McCulloch says. Most patients feel less osteoarthritis pain by the end of a series of three or more injections given weekly (dosing varies by manufacturer). A single-injection product is available, but it’s not yet clear if it’s as effective as a series, McCulloch says. If someone feels relief for a year, it might be worth getting another series of shots, says Peters.“But if you only get a month’s relief, I wouldn’t give it again.” Does it prevent the need for surgery? HA doesn’t stop cartilage deterioration, but it can relieve pain and stiffness and make moving around easier. And it can delay an operation as long as osteoarthritis hasn’t worn away all the cartilage, leaving bone on bone, says Peters. “Then, even hyaluronic acid injections don’t buy a lot of time,” he says. What are the side effects? HA injections are generally safe, though they’ll occasionally produce an allergic reaction, says Peters. You also can have some pain and swelling around the injection site, especially if the needle is injected into tissue instead of joint space, says McCulloch. When receiving injections, you have to rest the joint and avoid strenuous activities. For example, no running or jumping, Peters advises. Is it approved only for the knee? The Food and Drug Administration (FDA) approved it for knee osteoarthritis symptoms in 1997, says Salk, who participated in the first study of HA ankle injections in 2006. But “osteoarthritis is osteoarthritis, whether it’s in the knee, shoulder, hip or ankle,” he says. “Many doctors use hyaluronic acid on multiple joints as an off-label application.” “The FDA [might] approve it for multiple joints in the next few years,” he adds. How does HA compare with corticosteroids? Several recent studies indicate that the effects of HA injections last longer than corticosteroids, although the latter provides faster relief. HA injections were effective after four weeks, reaching their peak by week 8, with some residual effect at 24 weeks, according to a 2011 Tufts University analysis of 54 study trials involving 7,545 people with knee osteoarthritis symptoms. Their effect was greater than that of acetaminophen and NSAIDs, the study found. HA is also available as a nutritional supplement, but its effectiveness as an osteoarthritis treatment hasn’t been well-studied. “I think one day we’ll ingest hyaluronic acid in a pill in our 20s or 30s with proven benefits for joints,” Salk says. To learn more, visit our Osteoarthritis Health Center. Are You Bad to the Bone? For years, you’ve been the first one on the tennis courts, the weekend hiker, the intrepid gardener on your knees for hours. While all those activities are great for you, they can also be hard on your joints.